Administrative Withdrawal Request
In the event you were unable to withdraw from your course(s) by the deadline determined by College policy due to
extenuating circumstances, you may submit this form and all required documentation to request an administrative
withdrawal exception to the College policy.
Requests may be submitted up to 24 consecutive months from the end date of the term for which the administrative
withdrawal is being requested. Forms received after the deadline, and/or without all required documentation, will
not be reviewed. We will email you at your student.cscc.edu address with the results of your request. Approval of this
request is not guaranteed.
Student Name: ____________________________________ Cougar ID: ________________________
List Cougar ID# on all attachments.
Indicate the
_____ Autumn ______ ______ Spring ______ ______ Summer ______
Indicate each item completed and/or documents attached – ALL items MUST be completed prior to submission:
_____ Personal statement detailing why you were unable to withdraw from the course(s) by the deadline date.
Be very specific in your explanation of circumstances and include dates of related events.
_____ Official third-party supporting documentation. Examples of possible documentation may include:
Physician, hospital, or Advocate statement verifying your personal statement.
Obituary of a member of your immediate family such as parent, step-parent, sibling, grandparent,
stating your relationship to the deceased.
Copy of official orders for military active duty assignment to a different area, state, or country.
Letter from an administrator, faculty member, or staff member verifying a college error.
Submit this completed form and all required documentation by email to tarawforms@cscc.edu or to Student
Central/Student Services (addresses above). If you have questions, contact us at 614-287-5353.
Certification
I understand, for any courses for which my Administrative Withdrawal Request is approved, a grade of “AW” will replace the
previously
assigned grade and my cumulative Grade Point Average will be recalculated.
By listing my name below and submitting this electronic form, I certify all the information reported is complete and correct. I
also confirm the named person listed below executed this document in its entirety.
________________________________
________ ________________________
Student Signature (Required) Date
Indicate the term and year for which you are requesting an administrative withdrawal (one form per term):
Autumn _________ Spring _________ Summer _________
List Course Name and Number for which an administrative withdrawal is being requested (please print clearly):
_____________________________________
______ ___________________________________________
___________________________________________ ___________________________________________
