rev. 07/2012 1 of 1
I, ____________________________ ________________________ _______________________
Family (Last) Name First Name Date of Birth (MM/DD/YYY)
intend to withdraw from Houston Community College on _________________________________.
Date (MM/DD/YYY)
I understand that my responsibilities for a successful withdrawal may include, but are not limited to,
withdrawing from my classes, reconciling my bill with the HCC Cashier/Bursar’s Office for payment or
refund. In addition, if employed on campus, I must end my employment no later than the date of
withdrawal stated above.
As an F-1 student I am required to depart from the United States within fifteen (15) days following the
authorized withdrawal date as indicated above. The International Student Advisor/Designated School
Official (ISA/DSO) will report the withdrawal in the Student Exchange Visitor’s Information System
(SEVIS) and terminate (end) the F-1 student status in the record. I have attached a copy of my travel
document/s to leave the country.
If I choose to resume studies on an F-1 visa in the United States in the future, I am aware there will be
new requirements that must be completed. I understand I will need a new SEVIS I-20 Form and may
be required to attend another visa interview before being able to continue my education in the US.
Reason for Withdrawal:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I certify that I have read the information above, and that I fully understand my responsibilities before
withdrawing from Houston Community College.
_____________________________ _________________________________ ________________
Student Name (please print) Signature Date (MM/DD/YY)
________________________________________________________ _________________________
International Student Advisor/Designated School Official Signature Date (MM/DD/YY)
Notice of Intent to Withdraw Form
HCC ID:___________________________
SEVIS ID: ___________________________
