Administrative Withdrawal Request Form

Administrative Withdrawal Request Form
This form for should be used when a student is requesting an administrative withdrawal from a class due to missing the published withdrawal date.

Students must submit separate Administrative Withdrawal Request forms for each class for which they are requesting an administrative withdrawal.
Student Name*

First NameLast Name
Student Email*
example@example.com
LoLA/Banner ID:*
Birth Date*

MonthDayYear
Date
Semester*
Phone Number*
Please enter a valid phone number.
Program/Major*

Enter course information*

	CRN	Course	Section	Credit Hours
1

Why are you seeking an administrative withdrawal? What prevented you from withdrawing yourself prior to the withdrawal deadline?
This request requires approval from an academic dean. Please select the appropriate division the course listed above falls under for approval*
Signature*

Clear
Date*

MonthDayYear
Date
Upload any documentation that will support your request.

Cancelof
To be completed by the Registrar
Registrar Comments
Reviewed or Processed By:*

First NameLast Name
Date Processed:*

MonthDayYear
Date
Should be Empty:

To be completed by the Registrar