REGISTRAR STAFF ONLY
Date Received: _______________
Received by:_________________
Date Processed: ______________
Return to the Office of the Registrar | IST Room 2052 | (863) 874-8540 | registrar@floridapoly.edu
Course Withdrawal Request
Please complete all required fields in pen and obtain all required prior to submitting form to the Office of the
Registrar. This form to
request withdrawal
from
individual
course(s);please refer to
FPU-5.01034AP
Student
Withdrawal Policy.
If seeking to withdraw from all courses for the semester, you must complete a Student
Withdrawal Request (see
FPU-5.01032 Student Withdrawal from the University Policy).
LAST: _________________________________________ FIRST: ___________________________________ MI: _____
STUDENT UID: __________________________________ EMAIL: ______________________________@floridapoly.edu
Status: Undergraduate Graduate Withdrawal Semester/Year: _________________________
Course Withdrawal Reason (
REQUIRED
):
_
__________________________________________________________________________________________________
Step 1: Enter Course Information (Submit one form per course – if withdrawing from more than one course)
Step 2: Obtain All Required Signatures (Field Numbers 3-4 are required if applicable to student)
By signing below, you are confirming that you have been notified of student’s desire to withdraw from the above course.
1.
Instructor’s Signature: Date: _ ______________
a.
If student is receiving VA Benefits, please provide their last date of attendance:
_____
_____
2.
Academic Success Coach Signature:
Date: _________________
3.
Financial Aid Office Signature:
Date: _________________
(Required if student is receiving any form of financial aid; grants, loans, scholarship, prepaid program, etc.)
4.
International Student Advisor’s Signature
(If applicable):
______________________
Step 3: Student Confirmation
My signature confirms that I understand the course withdrawal policy and have considered the potential impact this
withdrawal may have on my academic standing and eligibility. I request to be withdrawn from this course.
Student’s Signature: _ Date:
click to sign
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