450 North Avenue • Battle Creek, MI 49017-3397
(269) 965-4129 • kellogg.edu/registrar
1. You are encouraged to speak with your instructor prior to withdrawal.
2. Print rmly with a ballpoint pen.
3. Return the form to the Records and Registration oce, Eastern Academic, Fehsenfeld, Grahl, or RMTC oce.
4. Add your reason for withdrawal.
NAME KCC ID or SOCIAL SECURITY NUMBER
Last Name First Name Middle Initial
CHECK (3) SESSION, ENTER YEAR FALL 20 SPRING 20 SUMMER 20
REASON FOR WITHDRAWAL
NUMBER COURSE TITLE
FOR OFFICE USE ONLY
White - Registrar‘s Oce Canary - Student Copy