WITHDRAWAL FROM COLLEGE *Please submit a form of ID (copy of license, student ID) along with this document* SSN or Student I.D. Student Name Street Address City, State, Zip Code Student Major Campus Semester/Year of Withdrawal Last Date of Attendance RECEIVING BENEFITS FROM (Check All That Apply): TAP
VETERANS
SS
TITLE IV FUNDS:
PELL
LOANS
REASON FOR WITHDRAWAL:
COUNSELOR SIGNATURE
DATE
STUDENT SIGNATURE
DATE
WITHDRAWAL CODE
PECENTAGE OF REFUND
The withdrawal form originates in the Counseling Center. Refunds will be calculated from the date the withdrawal procedure is completed. The Admission Fee, Activity Fee and Accident Insurance are not refundable. Tuition refunds are made at the following rates to students who withdraw: prior to the first day of Fall or Spring Semester: 100%; during the first week of instruction: 75%; during the second week of instruction: 50%; during the third week of instruction: 25%. NO REFUNDS WILL BE MADE AFTER THE THIRD WEEK OF INSTRUCTION. (For Complete Statement, See College Catalog) Distribution:
White: Registrar
Date Processed Initials Rev. 9/15 RegC Forms.college withdrawal.doc
Yellow: Counseling
Pink: Department
Goldenrod: Student