OFFICE USE ONLY: Processed Date _____ Initials _____ 04/16
Office of the
300 The Fenway, Boston, MA 0
Tel 617.521.2111 Fax
WITHDRAWAL FROM ONE PROGRAM IN A DUAL-DEGREE PROGRAM
Student should complete this form if they are planning to drop one program of a dual degree program.
To ensure that all records are up to date, Simmons requires students to obtain the permission of both
program directors involved in the dual degree.
Students are also required to obtain the signature of the Student Financial Services office. Often changing
from a dual degree program to a single degree program will result in a change of tuition and of credits
required for the single degree.
Students intending to complete both halves of a dual-degree program, but receive their degrees on
different dates, should not use this form. Students may contact the program director to determine whether
receiving degrees on separate dates is permitted in the program and fill out the appropriate form if so.
: ________________________________ Si
Semester of withdrawal from the program: Fall/Year_______ Spring/Year________ Summer/Year______
Primary Reason(s) for Withdrawing from Program: __________________________________________________
Withdrawing from program:
New Anticipated Graduation Date for Remaining Program: ______/________
Student’s Signature: _______________________________________________ Date: _______
(Remaining) Program Director: ______________________________________ Date: _______
(Withdrawal ) Program Director: _____________________________________ Date: _______
Student Financial Services Counselor: _______________________________ Date: _______
Please return completed form to the Office of the Registrar.
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