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A WITHDRAWAL is a complete removal from the (Fairleigh Dickinson University)

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A WITHDRAWAL is a complete removal from the University. If you chose to return to FDU, you must re-apply through the Admissions Office.
INSTRUCTIONS: Please provide the information requested below, obtain the appropriate signatures required, and return the form to the Enrollment
Services front desk (Office 203) or by e-mail at esvancouver@fdu.edu. Students applying for a withdrawal are responsible for paying any outstanding fees
with the university.
Last Name:
First Name:
Student ID:
Program Major:
E-mail:
Home Phone:
Cell Phone:
Academic Advisor: _________________________________________
Are you receiving Financial Aid from a Canadian Provincial financial aid program, or a financial aid program in the United States? YES NO
For the reason stated below, I intend to withdraw. Effective Date: _______________________
Reason(s):
Medical:___________________________________________________________________________________
Transfer - Name of New Institution: _____________________________________________________________
Financial: __________________________________________________________________________________
Academic: _________________________________________________________________________________
Employment: _______________________________________________________________________________
Other: _____________________________________________________________________________________
I understand that I am responsible for my outstanding financial obligations for the University. I understand that if I am receiving financial aid through a
government program, that withdrawing may affect my financial aid and that it is my responsibility to contact the appropriate agencies to notify them of my status.
Student Signature: Date:
APPROVAL:
______________________________________ ___________________
Academic Advisor Signature Date
______________________________________ ___________________
Student Services Signature Date
______________________________________ ___________________
Student Accounts Signature Date
______________________________________ ___________________
Enrollment Services Signature Date
Effective Date of Withdrawal: Withdrawing in good standing: Yes No
ID Card Deactivated
Date:
Initials:
Colleague Update
Date:
Initials:
CIC report Updated
Date:
Initials:
*Copies: Academic advisor, Admissions, Enrollment Services, Financial Office and Student Services.
Comments:
FDU V-Official Notice of Withdrawal – Nov 2015
ADDRESS
Street:
Province/State:
Apartment #:
Country:
City:
Postal Code:
TO BE COMPLETED BY RECORDS OFFICE Date:_________________
CGPR
CUM. CREDITS
CHECKED BY:
Official Notice of Withdrawal
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Completed 21 August 2020

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