Tennessee Tech | Office of the Registrar | Jere Whitson Building, Room 221 | 931.372.3317 | registrar@tntech.edu | tntech.edu/em/records/
Office of the Registrar
TENNESSEE TECH
Student Name: _____________________________________________ T#: __________________ Term: _________
(Last) (First) (MI)
Student Email: _______________________________________________
Student Signature: ____________________________________________ Date: ___________________
This request is for (please select one field): 100% refund _____ 75% refund _____ 25% refund _____
My request is due to:
Withdrawal from the University ______ -or- Dropping the following course(s) _____________ _____________
(Example: ENGL 1010-001)
_____________ _____________
_____________ _____________
Provide a detailed explanation for the basis of this request and attach any supporting documentation. Please be sure
to list the last date of class attendance. Use the back of this form for additional space if necessary.
Recommendation: Upon review of supportive documentation, a 100% _____ 75% ______ 25% _____ refund of
applicable fees has been recommended ______ denied ______.
Representative for Business & Fiscal Affairs: ____________________________________ Date: ___________
Fee Refund Committee Chair: ______________________________________________ Date: ___________
Requests are reviewed in accordance with TBR guidelines, which may limit some exceptions being granted.
Exceptions to the University’s refund policies will be reviewed only with proof of extenuating circumstances by
attaching supporting documentation to this request.
Please return completed form and proof of extenuating circumstances to the Business Office, window number 4.
