One College Drive
Calais, ME 04619
Enrollment & Student Services 207-454-1013
Instate: 800-210-6932
Fax: 207-454-1018
RE Form College Withdrawal PC: Advisor
Revised: July 8, 2019; amd
College Withdrawal Form
Last Name: ___________________________________ First Name: __________________________________ M.I.: _____________
Mailing Address: _______________________________________ City: ______________________ State: _________ Zip: ________
Phone Number: ___________________________________ Mobile Phone Number: ________________________________________
Cell phone carrier: US Cellular Verizon AT & T Tracfone Other __________ Text Updates: ___Yes ___No
Student ID #: _____________________________ Email address: ______________________________________________________
Program of Study: ____________________________________________________________________________________________
The student is responsible for completing A and contacting officials in B, C, D, E, F, G and H for their completion. The completed
form should be returned to Donna Geel.
A: To be completed by Student: I _______________________ officially withdraw from WCCC as of ____________________ for
the following reasons:
___Academic Difficulty
___Disciplinary Action
___Financial Problem
___Personal Heath
___Military Service
___Personal Problems
___Employment
___Loss of Interest
___Career Objective Undecided
___Other, please specify _____________________________________________________________________________________.
________________________________ _________________________
___________________
Student’s Signature Date last class attended
Today’s Date
B. To be completed by Student’s primary instructor or advisor: The student has talked to me about leaving school. And has or
has not (circle one) returned all tools and equipment. (Details should be provided to the Business Office if he/she has not)
________________________________ ___________________
Instructor’s Signature Date
C. To be completed by the Director of Residential Life (if applicable): This student has talked to me about leaving school and has
or has not (circle one) returned the apartment key. If returned date: ___________.
Student is reminded to complete the apartment conditions report prior to leaving. Security deposit can or can’t (circle one) be
returned. If deposit cannot be returned, please state reason(s)__________________________________________________________
________________________________ ___________________
Director of Residential Life’s Signature Date
D. To be completed by Librarian: This student has or has not (circle one) returned all books and other materials on loan from the
library. (Details should be provided to the Business Office if he/she has not).
________________________________ ___________________
Librarian’s Signature Date
E. To be completed by the Associate Dean of Student Affairs or the Dean of Students: This student has seen me about leaving
school. The student’s future plans are_____________________________________________________________________________
____________________________________________________________________________________________________________
(OVER)
Non-Discrimination Policy
: Washington County Community College is an equal opportunity/affirmative action institution and employer.
For more information; please call Tatiana Osmond, Affirmative Action Officer, at 454-1094.
One College Drive
Calais, ME 04619
Enrollment & Student Services 207-454-1013
Instate: 800-210-6932
Fax: 207-454-1018
Non-Discrimination Policy
: Washington County Community College is an equal opportunity/affirmative action institution and
employer. For more information; please call Tatiana Osmond, Affirmative Action Officer, at 454-1094.
RE Form College Withdrawal PC: Advisor
Revised: July 8, 2019; amd
F. To be completed by the Financial Aid Office He/She has ____ has not ____ applied for financial aid.
As part of your financial assistance, did you receive a Stafford Loan (Subsidized, Unsubsidized and/or did your parents receive a Plus
Loan? Yes ___ No ___
If yes, you will need to complete an Exit Interview either electronically or manually. This will take approximately a half hour of your
time. In order to complete this, you will need the following:
Complete address and telephone number of the nearest relative not living with you*required by federal regulation
Two personal references with complete address and telephone numbers *required by federal regulation
If you are leaving for employment, complete name, address and telephone number of your employer*required by federal
regulation
Exit Interview Completed: Yes __ No ___ Comment: ______________________________________________________________
____________________________________________________________________________________________________________
Title IV aid is earned in a prorated manner on a per diem basis up to and including the 60% point in the semester. Title IV aid and all
other aid is viewed as 100% earned after that point in time. Please review policies in Student Financial Aid Handbook.
Percentage of Title IV aid earned: ____________
Total Title IV Aid to be Disbursed or Returned: Federal Unsubsidized Loan__________________
Federal Subsidized Loan_____________
Federal Pell_______________________
Federal SEOG_____________________
____________________ ____________________________________
Date Financial Aid Director’s Signature
If a student is a Title IV Recipient, a copy of an estimated Title IV refund worksheet should be forward to the Business Office.
G. To be completed by the Student Accounts; Student Accounts Representative: Please attach Bill
Balance due if any______________.
Steps for collection ___________________________________________________________________________________________
Explanation/Notes:____________________________________________________________________________________________
________________________________ ___________________
Student Account Representative Signature Date
(OVER)
For Office Use Only
Processed: __________________ __________________
Initials Date
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