Request for Withdrawal
Last Name: First Name: MI: Student ID:
Mailing Address: City, State, Zip:
Semester: □ Fall □ Spring □ Summer I □ Summer II □ Winter Year (Select only one)
Do you receive any of the following? □ Financial Aid □ Veterans Benefits
Are you withdrawing from all of your classes? □ Yes □ No If no, list courses to be withdrawn below:
CRN Subject Number Course Title Credit Hrs
Total hours after change:
Reason for Withdrawal (Check all that apply and please explain below)
□
Dissatisfied with academic performance
□
Dissatisfied with my classes
□
I feel misadvised
□
College experience not as expected
□
I was not aware of college procedures
□
Changing major or career path
□
Unsure of my academic goals
□
Not enough money to continue
□
Not enough financial aid
□
Unable to purchase books
□
Transportation issues
□
Moving
□
Transferring to:
□
Military/deployment
□
Work schedule
□
Illness
□
Taking care of friend/family member
□
Childcare issues
□
Life crisis
□
Issues due to COVID-19/Coronavirus
(please explain below)
□
Other/Explanation:
Student
Initi
als
Office
Staff Signature
Advisor/Student
Success Center
I understand a “W” Withdrawal grade will be listed on my transcript
for course(s) listed above if I withdraw after the semester has begun.
Financial Aid
My financial aid status may be negatively affected.
I understand that I am responsible for exit counseling (if required.)
Title IV? □ Y □ N
I understand that I am responsible for paying any financial obligations and I may not be entitled to a refund.
Student Signature Date
Student should receive a copy of completed and signed form
before issuing original form to the Office o
f the Registrar.
Students are responsible for ensuring this form is turned in.
Staff Use Only
Registrar's Office
Date
Effective Date
Percent Refund
(if
applicable, no refunds will be
issued for partial withdrawals)
Additional Approval
Date
(if required)
Office of the Registrar
Revised 04/06/2020
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a
manual signature.
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