Academic Withdrawal Request
Current Term and Year (e.g. FA 2019): __________
Student ID or ACNET ID:_______________________
Student Name: ______________________________
Student Signature: ___________________________
STEP 1: Speak to Instructor(s) and Get All Needed Signatures
Course Name, Number, Section
(Example: ENGL-1301-001)
Instructor Printed Name
Instructor Signature
STEP 2: Student Must Complete this Section
Do You Receive Financial Aid?
(Please Check Response)
Yes and I have read the following:
Dropping all courses before you reach the 60% point of the semester could result in
you having to pay back some of your financial aid funds.
Students who receive federal financial aid funds are required to maintain a 67% pace
of completion or complete at least 67% of all the attempted courses. Withdrawing from
a course will result in a non- completion and will affect your Pace of Completion.
Please contact 806-371-5313 with additional questions regarding course withdrawal.
Do You Receive Veteran
(Please Check Response)
Submit completed form to Veterans Benefits Coordinator. Room: SSC 151B
Reason for Withdrawal
(Please Check Main Reason):
Computer/ Technical Difficulties
Do Not Need Course
Family Death
Family Illness
Financial Issues
Instructional Issues
Student Illness
Student Work Schedule Change
Other (Provide Reason Below)
STEP 3: Submit this Form to AskAC or Registrar’s Office by the Course Withdrawal Deadline
IMPORTANT NOTE ON THIS STEP: Forms that are submitted by the withdrawal deadline will be processed using the
drop/withdrawal date that the form is received by AskAC or Registrar’s Office. Students who have questions related
to this form should contact the Registrar’s Office (
; 806-371-5036) for assistance. Students who
would like to be considered for an exception to withdrawal, can complete and submit the Exception to Withdrawal
form to AskAC or Registrar’s Office staff.
Date Form Received: _________
Processed By (Initials):_________
Please complete electronically or use a blue or black ink pen to complete this form. Unless otherwise indica
ted, all sections must be fully completed.
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