LATE WITHDRAW REQUEST
Return to: DeanofEnrollmentServices@icc.edu or
Enrollment Services, 1 College Drive, East Peoria IL 61635.
If you have any questions, you may call (309) 694-5323.
Updated 2020
Withdrawal from courses after the end of semester will be allowed only when justified by
unforeseen, serious and extenuating circumstances outside the student’s control.
Please refer to the Late Withdraw Requests Policy and Procedure before completing this form.
CERTIFICATION STATEMENT
I hereby certify that the information provided is accurate and true. I, the student, have completed this request and included a
written explanation (neatly written or typed) and supporting documentation. I understand the decision is final.
Student Signature Date
The request will be reviewed by the Dean of Enrollment Services for recommendation/approval.
The final decision will be communicated to you via official communication from the Dean of Enrollment Services.
FOR OFFICE USE ONLY:
Comments:
Signature: __________________________________________
Dean of Enrollment Services
Extended illness/hospitalization of student
or immediate family member
Death of an immediate family member
The following information is required to submit your
request. Please check to confirm it is included:
Supporting documentation is included
Typed or neatly handwritten explanation is included
Please see the Late Withdraw Requests Policy and
Procedure for more information on supporting
documentation and the typed/written explanation.
___________________________________________________________________________________________________
Student ID Number Last name First Name MI Phone
__
_________________________________________________________________________________________________
Address City State Zip
The affected courses were during the:
FALL SPRING SUMMER semester of
(Please check one) (year)
The following courses were affected:
