Name: _________________________________  Social Security #:  _________________

Current Address: ____________________________________________

City: ______________________  State: ______  Zip: ______  Telephone: _________________

Martial Status:  __ single  __ married  __ widowed  __ divorced

Reason for Leaving:  __ academic dismissal  __ disciplinary dismissal  __ financial difficulties
                                        __ illness  __ other (please specify): __________________________ 

If you have been dismissed for Academic or Disciplinary reasons, please explain why you feel that you should be considered for readmittance. State the factor(s) which have changed since you left XU.  (attach separate sheet)
Last Date of Attendance at Xavier: _______________________

Have you attended any other college/university since leaving X.U.? ___________

Name of Institution: __________________________________  Dates Attended: _______________

If you have attended another institution, please have a current transcript forwarded to the Office of the Registrar
as soon as possible. If you are currently attending, please send your midterm grades.
Have you been in military service?  _____  Length of Time: _______________

Have you been employed during this time: _____  Length of Time: ____________

Employers Name: ________________________________________________

If none of the above statements apply, please state briefly what you have been doing since you

left Xavier. ___________________________________________________________

What major program do you wish to follow: ____________________

For what session do you wish readmission: _____________________

FOR STUDENTS ACADEMICALLY DISMISSED OR ON PROBATION AT THE TIME OF DEPARTURE FROM XAVIER: All materials, including the report from Xavier's Counseling Center must be received by the Office of the Registrar no later than one month prior to the registration date of the semester you wish to return. 
Please return form to: 
Office of the Registrar, Xavier University of Louisiana, 1 Drexel Drive, New Orleans, LA 70125
or fax the form to: (504)520-7922
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