WA: Academic Reason
WP: Personal Reason
W6: Called to Active Duty Military
(Must present copy of orders to Associate Provost)
COURSE WITHDRAWAL FORM
Please print legibly. Use black or blue ink only. Bring completed form to the Campus Admissions Records Office.
Student ID #: B____________________________ Last Name:___________________________________ First Name:_______________________ Term:____________________
CRN
Course Identifier:
Letters, Numbers, Section
Course Title
Instructor
If you have a new address please check the box and fill in the street, city, state, zip code and phone number. Address:_____________________________________________
_______________________________________________________________________________________________________________ Phone:__________________________
Are you a high school dual enrollment or early admissions student?
YES NO
If yes, you must complete the Dual Enrollment/Early Admissions Course
Withdrawal form.
Check all that apply: VA Financial Aid *Athlete *International Student
Athletic Office Authorization _________________________(*requires authorization)
International Advisor Authorization _______________________
IMPORTANT NOTICE: WITHDRAWING CAN NEGATIVELY IMPACT YOUR FINANCIAL AID AND/OR VA BENEFITS
• Student
s who withdraw from or stop attending all classes must repay a portion of their federal aid for the term.
• Bright Futures Scholarship recipients must repay EFSC for the cost of withdrawn course(s).
• Withdrawing from or not attending class(es) may negatively impact your Satisfactory Academic Progress and eligibility for financial aid and/or VA benefits.
Visit your campus Office of Financial Aid or MVSC Office if you have any questions about how withdrawing may impact your current or future eligibility.
I agree to pay any costs associated with the collection of unpaid, delinquent or defaulted charges, including collection costs, which may be based on a percentage not to exceed
33% of the debt, attorney fees and court costs. Faxed or scanned/emailed withdrawals must include a legible copy of student’s legal photo ID.
STUDENT SIGNATURE: _________________________________________________________________________________________________ Date: _______________________
Administrative Reason Codes:
W4: Administrative Withdrawal W5: Appeal
Approval Signature: ____________________________________________________________Date:________________________
Comments: ____________________________________________________________________________________________
Withdrawal from: __________________ Approval to remain in co-requisite:___________ Co-requisite Instructor Signature:____________________________________________
OFFICE USE ONLY: SFAREGS________________ Processed By:______________________________________ Date Processed: _________________
SCA-081 R081617
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