Office of the Registrar

WITHDRAWAL FORM

INSTRUCTIONS:

Fill in the fields on the form below.
Click on the Print Certificate button at the bottom of the form to generate your certificate
- This is important because the signature lines and valid certificate number are then displayed.
Print the Certificate using the print function of your web browser and indicate the number of copies desired.
Deliver completed Certificate to:
- Undergrad, College Special or Professional Students: your Academic Deans Office.
- Guest or Special Students: Division of Continuing Studies Office, 1305 Linden Drive.
- Grad Students: Dean's Office, Room 217 Bascom Hall.
NOTE: There are deadlines associated with the withdrawal process. Refer to (Deadlines at a Glance) for deadline dates.
IMPORTANT:This form does NOT submit electronically. You MUST print the certificate and deliver it appropriately.

STUDENTS:
LAST NAME	FIRST	MIDDLE

CAMPUS ID
(xxxxxxxxxx)

PROGRAM & YEAR

Term/Year

Reason

WITHDRAWAL DATE
mm/dd/yyyy

F1/J1 Student Visa Holder

Student Mailing Address:

Street Address
City State Zip Code

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