Office of Student Services
StudentServices@warren.edu
Copies to: Student, Financial Aid, Student Services
Rev. 12/2020
FALL 2020 MODIFIED COURSE WITHDRAWAL FORM
Directions: Students must complete form and obtain instructor signature(s) prior to submission to Student Services.
Please be guided by the directions at the bottom of the page regarding financial aid office notification.
Section 1: Student information - Complete highlighted fields
STUDENT ID #:
Last Name First Name: MI:
Address:
City State Zip
Email: Cell Phone: Home Phone:
SEMESTER and YEAR: FALL 2020
Section 2: Class Details - Complete highlighted fields
I am withdrawing from all classes: ☐ YES ☐ NO **** I am an NJ STARS student ☐ YES ☐ NO
A grade of “W” will be assigned for students who attended classes through November 2
nd
, 2020 and carries no academic penalty. Student who
stopped attending prior to November 2
nd
, 2020 are not eligible for withdrawal. Forms must be submitted no later than December 22, 2020.
Example: Student completes course details as in this example:
Principles of
Accounting I
Please complete one row for each course from which you are withdrawing:
Course Dept. Code Section
Credits
Course Title Grade
Instructor Signature
W
Reason for withdrawal: (Check one)
☐ Instructor ☐ Scheduling ☐ Academic ☐ Financial ☐ Family/Personal ☐ Other. Please specify reason:
Section 3: Financial Aid Information - Check and complete highlighted fields
Financial Aid: Students MUST meet with the Financial Aid Office prior to processing a withdrawal form if they are receiving any grants, loans,
work-study, or Veterans Affairs benefits.
Check one:
☐ I am NOT receiving financial aid
☐ I am receiving financial aid and I consulted with Financial Aid representative (Name): Date:
Student Signature_________________________________________________________________ Date:
Processed By: Date:
Required: Check one and enter the date.
* = Required field
W
W
W
W
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*
*
*
*
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*
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*
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