Course Withdrawal Form
Complete this form in its entirety and click submit. Your academic advisor will contact you at the e-mail address or phone number you have entered for any additional information or counseling. Please review the following information prior to submission:

Refund schedule

Timeline for withdrawal without academic penalty

Extension policy


* Required Information

Your Contact Information
First Name:*

Last Name:*

Address:*

City:*

State:*

Zip:*

Country:*

Home Phone Number:
Format: 555-111-9876

Mobile Phone Number:
Format: 555-111-9876

Work Phone Number:
Format: 555-111-9876

International Phone Number:

Preferred Contact Phone Number:*

Time Available:

Email Address:*


Request
Is this a course or program withdrawal?*


If course, which course(s) are you withdrawing from?

Withdraw Course 1:

Withdraw Course 2:

Withdraw Course 3:

Withdraw Course 4:

Advisor Name:*

Withdraw reason:*

Explanation:*




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