ADMISSIONS AND RECORDS OFFICE
PETITION TO WITHDRAW FOR NON-ATTENDANCE
FOR CURRENT TERM ONLY
Section I: To be completed by student
Student Name:
Address:
Student ID#:
Phone #:
Email:
I hereby request to withdraw from the following course because I did not attend the class at all:
Schedule #: Course: Current Term:
Student’s Signature: Date:
Section II: Instructor certification of non-attendance of student:
TO: Instructor Name:
FROM: Admissions and Records:
The student listed above has requested an official drop from your class based upon non-attendance (no show).
Please confirm their eligibility for this no-show drop by completed the applicable statement(s) below and by signing and
dating the form. Return the completed verification to Admissions and Records.
1. The above referenced student did NOT attend class at all:
YES: NO:
The student was active at Census YES: NO:
If student’s attendance has been certified as having attended the class as of the census point, and student did
not attend the class at all, an explanation is required:
2. The above referenced student’s last date of attendance in class was:
Instructor’s Signature: Date:
Section III: ADMISSIONS AND RECORDS OFFICE USE ONLY
Enrollment date per XCSU: / / Enrollment status code: N A Verified by:
Census Roster Certified: YES NO Received date: / / Date to Instructor: / /
Student attended class and did not drop prior to refund or drop deadline.
Student added class on or after the 1
st
day of class session.
Other:
APPROVED DENIED BY: DATE:
Admissions & Records Manager
Processed by: Date Processed: Copy to Student date:
Withdraw_for_Nonattendance_ACC_02082018
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