One College Drive
Calais, ME 04619
Enrollment & Student Services 207-454-1013
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:
___Career Objective Undecided
___Other, please specify _____________________________________________________________________________________.
Student’s Signature Date last class attended
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_____________________________________________________________________________
: 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.