Attachment II

APPLICATION TO REMOVE RE-ENROLLMENT BLOCK

Name:

Last First Middle

Mailing Address:

Phone: ( ) Student I.D. No.

Date of Withdrawal Semester/Yr. desired for re-enrollment

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I hereby submit my application for re-enrollment. I understand that I may be required to have a re-enrollment questionnaire and letter of recommendation completed by a psychiatrist or licensed psychologist prior to consideration of this application.

I understand that said questionnaires and recommendations may be used by officials at the University when considering my application for re-enrollment.

I understand that only approval by the Vice President for Student Affairs of my re-enrollment meets the conditions for removing the re-enrollment block from my records. I further understand that, if approved, I must contact the Admissions Office to complete the re-enrollment process.

Finally, I give my consent that my treating psychiatrist, other physician, or licensed psychologist may release pertinent information to the Office of the Dean of Students and the Counseling Center needed for the evaluation of my re-enrollment application. I hereby agree that a photocopy of this release is a legal equivalent of the original document.

Signature Date

After completion of this form, please submit to:

Office of the Dean of Students

Texas State University-San Marcos

601 University Drive

San Marcos, Texas 78666