University Withdrawal Form
University Withdrawal Form
Please fill out the form with your information below.
Student Information
Name
Student ID Number
Date of Birth
Email Address
Phone number
Withdrawal Information
Date of Withdrawal Request
Term of Withdrawal
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Fall
-
Spring
-
Summer
Reason for Withdrawal
Check all that apply
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Medical reasons
-
Personal reasons
-
Financial hardship
-
Transfer to another institution
-
Academic issues
Financial Information
Outstanding Balance
Refund Eligibility
Refund Amount
Housing Information
Room Number
Move-Out Date
Course Withdrawal
List all enrolled courses
Acknowledgment
By signing below, I confirm that I am formally withdrawing from [University Name] and understand that this withdrawal may affect my academic progress, housing, and financial obligations. I also acknowledge that I am responsible for any outstanding balance and understand the university’s withdrawal policies.
Student Signature
Date
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