Revised 7/9/2015
Step 1:
Print Name: ____________ _____________________________ _ Student ID #: ___________________ ____
Last First Middle Required
Withdrawing from all courses? Yes _____ No _____ Semester: Fall ____ _ Spring __ ___ Summer I ___ _
Year Year Year
Step 2:
Dept./Course Number/Section
Course Title
Instructor Signature (Main Campus)
Step 3:
Circle one primary reason for withdrawal (your accurate response is important to us!)
Z1. Coursework too difficult/Too fast paced
Z2. Difficulty submitting online coursework
Z3. No Internet access at beginning of term/Loss access after term began
Z4. Prefer classroom instruction (vs online course)
Z5. Did not commit 6 hours outside of class/Study Habits
Z6. Moving out of area
Z7. Loss/no interest
Z8. Employment or Transportation
Z9. Administrative Withdraw
Step 4: (All Signatures Required)
Principal/Counselor Signature: ____________________________________________________________________________________
Advisor Signature:
Academic and Financial Aid Policies. Credit attempted and earned will be posted to a college transcript and becomes a part of the
student’s permanent academic and financial aid record. The grades earned as well as credit attempted and earned will be included
in all grade point averages and completion rates to determine Satisfactory Academic Progress for both academic and financial aid
Student Signature: _____________________________________________ Bal. Due: ____________________________________
Parent Signature: _______________________________________________________________________________________________
Office Use:
Received by: ________________________________
Date: ______________________________________
ANC Early College Program
Drop/Withdrawal Form
(870) 780-1200
2501 South Division
P.O. Box 1109
Blytheville, AR 72316