Date Verified
Verified By
Required Documentation
Complete N/A
☐ ☐ ☐ ☐ ☐ ☐
☐ ☐ ☐ ☐ ☐ ☐ ☐
SEPC written recommendation
Program Director decision
Notice of Dismissal or other written decision delivered Registrar, Financial Aid, Student Accounts, and Dean notified
Clinical site(s) notified, if applicable
University appeal and outcome documented, if applicable
Record filed in secure student educational record ☐
STUDENT ACKNOWLEDGMENT I acknowledge that I have been provided access to the NLU Master of Science in Physician Assistant Studies Student Dismissal Policy, that I have had the opportunity to ask questions about it, and that I understand that additional NLU University policies and procedures may apply.
Student Name: ______________________________________ Student Signature: ______________________________________ Date: ______________________________________
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