Registrar’s Office
Instructor Approval Course Withdrawal
After Two-Thirds of the Semester
Please complete this form, sign, date, and return it to the Registrar’s Office in SSC L157. DEADLINE: This form must be received in the Registrar’s Office by the last day of classes.
STUDENT INFORMATION
First Name MI Last Name
Mailing Address
City State Zip
Home Phone Number Cell Phone Number Work Phone Number
Banner ID Number Are you receiving veteran’s benefits? Are you receiving financial aid?
n
Yes
n
No
n
Yes
n
No
Subject/Course # CRN #
I request permission to withdraw from the following course: Semester Year
Credits Course Title
REQUIRED BY STUDENT
COURSE WITHDRAWAL POLICY: This form must be approved and signed by the instructor, then returned by the student to the Registrar’s office by the last day of classes. If the
withdrawal is approved, a “W” will be recorded on the student’s transcript. If a student stops attending and fails to withdraw officially from a course, a grade of “F” may be recorded on the
student’s transcript. In all cases of withdrawal, a “W” does not affect the student’s grade point average.
WITHDRAWAL FROM THE COLLEGE: A student who withdraws from the college must complete a withdrawal form at the Registrar’s office. Failure to officially withdraw in writing from the
college may result in failing grades for uncompleted courses and might result in probation or suspension status. (See online college catalog from more information)
Reasons for Withdrawal
Please sign and date to authorize withdrawal of course.
Student Signature
Date
REQUIRED BY INSTRUCTOR
By signing this document, I approve withdrawal from this course.
FOR REGISTRAR OFFICE USE ONLY
Date Received _____/______/_______ Processed By _______________________________________________
Date _____/______/_______
Instructor Name
Instructor Signature
Remarks
Date
September 2017/PR
