For Office Use Only: Date Received and Processed: ____________________________
Rev 4/20 – Web Version
MIDDLESEX COMMUNITY COLLEGE
WITHDRAWAL FORM – AFTER THE REFUND DATE
S
igned form must be delivered, faxed (860-344-3055), or emailed (mx-enrollmentservices@mxcc.edu
) to the
Office of Enrollment Services by the close of business on the deadline date. No forms will be accepted after the
deadline. Please consult the Academic Calendar for the deadline date. Failure to submit this form by the deadline
may result in a grade of “F” for the course.
(SSN required if Student ID is left blank; however, if
emailing do not put SSN, we will contact you if needed.)
Student ID @______________________ OR Social Security No. ______/_____/_____
N
ame_______________________________________________ Phone #_______________________
Student Signature_____________________________________ Today’s Date ___________________
Please Check One: Withdrawal from ALL Courses from the Current Semester
Withdrawal from ONLY those courses listed below (EACH COURSE INSTRUCTOR’S
SIGNATURE IS REQUIRED)
Semester: Fall Spring Summer Winter Intersession Year: ________
FINANCIAL AID and/or VETERAN’S BENEFITS may be affected by your withdrawal. Make an appointment with the
Financial Aid Office or the Veterans Counselor PRIOR to submitting this form.
Financial Aid Recipient: Yes No Veterans’ Benefits Recipient: Yes No
________________________________________ ___________________________________________
Financial Aid Representative Signature
(If Applicable) Veterans Representative Signature (If Applicable)
Reason for Withdrawal:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
COURSE TITLE
(ex. Composition)
INSTRUCTOR’S SIGNATURE
(Required for Individual Course Withdrawals)
ALL DEBTS are the responsibility of the student and must be paid immediately.
