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, 21 N. Park Street, Suite 7101.
    • 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