Semester:   Year:

   _____Fall   20___

   _____Spring   20___

    _____Summer 20___

Withdrawal From College Form

Student Name: ______________________________________    Student ID#: __________________

Major: _____________________________________________    Advisor: _____________________

Date of Withdrawal: _________________________________      

Expected Return Date:  Semester:_____________  Year: ______________

Reason For Withdrawal

Ineligible for Financial Aid____    Financial Problems____    Medical____

Family Responsibilities   ____    Employment   ____    Military____

Other (Please elaborate)   ____    Childcare   ____

Comments/Referrals

________________________________________________________________________________

________________________________________________________________________________

Courses To Be Dropped:

Course Prefix/#_________ Sec. No. ____ Hrs.______  Course Prefix/#___________ Sec. No. ____ Hrs.______

Course Prefix/#_________ Sec. No. ____ Hrs.______  Course Prefix/#___________ Sec. No. ____ Hrs.______

Course Prefix/#_________ Sec. No. ____ Hrs.______  Course Prefix/#___________ Sec. No. ____ Hrs.______

Course Prefix/#_________ Sec. No. ____ Hrs.______  Course Prefix/#___________ Sec. No. ____ Hrs.______

Financial Aid→ Comments/Referrals

_______________________________________________________________________________

_______________________________________________________________________________

Library→ Comments/Referrals

__________________________________________________________________ ____________________________

______________________________________________________________________________________________

Student’s Signature:________________________   Date:_______________________________

Advisor’s Signature:_________________________    Date:_______________________________

Original: Registrar’s Office; Copy: Student

Form 1442/003 (4/05)

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