ADN Re-Take Form

First Name:
Last Name:
ACC ID#
Mailing Address:
City:
State:
Zip Code:
Home Phone:
Alternate Phone:
Email:
Course Number from which withdrawn:
Date of Withdrawal from course (semester/year)
Semester requesting retake for (semester/year)
Track requesting retake for:
Online Onsite EVC Onsite CEC
I understand that I am allowed to retake the same course only one time.
Yes No
I understand that I am only allowed to retake a total of 9 semester hours in nursing.
Yes No
I understand that the deadlines for retake request submissions are: Spring (December 17th), Fall (June 5th), and Summer (May 5th).
Yes No