Revised 11/25/2019
Late Withdraw Request
Student’s Last Name
First Name
M.I.
D.O.B.
Street Address
Instructions:
A student may withdraw from any or all courses and receive a grade of “W” after the official withdrawal date ONLY if emergency or
extenuating circumstances exist.
To request a “W” after the final withdrawal date, the student must:
1. Complete this Late Withdraw Request (Please use one form per course!)
2. Complete a Registration Add/Drop form, available online or in Student Affairs
3. Obtain the recommendation & signature of the instructor if available
4. Submit both forms to the Academic Dean
a. A copy of the decision of the Academic Dean will be provided to the student and the instructor.
b. This form and the Registration Add/Drop form will go to the Office of Student Affairs.
Course
Information:
Department
Number
Section
Term
Class Title
Briefly list the emergency or extenuating circumstances, which resulted in your request to drop the course listed on the attached
Registration Add/Drop form and shown above. You may attach supporting documentation.
Student’s Signature:
Date
Instructor’s Section
Withdrawal Recommended
Withdrawal Not Recommended
LDA
Grade on LDA
Instructor’s Comments & Recommendation
Instructor’s Signature:
Date
Dean’s Section
Dean’s Comments & Recommendation
Approved
Not Approved
Dean’s Signature:
Date
Registrar’s Office Use
CRI:R-WITH Processed by ____________
PCEX:RD12AOWD
Student File cc: Instructor, Dean Date ____________
click to sign
signature
click to edit
click to sign
signature
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