MONTANA STATE UNIVERSITY BILLINGS
REQUEST FOR WITHDRAWAL
Student’s Name________________________________________________________________________________
(LAST) (FIRST) (MIDDLE)
ID #_____________________________________________ Phone #____________________________________
Email Address:________________________________________________________________________________
Mailin
g Address:_______________________________________________________________________________
City: ___________________________________________ State: ______________ Zip: _____________________
Term/Year Withdrawing From: Fall Spring Summer Year _________
______________
Last
Date Attended Classes (MO/DAY/YEAR): __________________________________________________________
REASON FOR LEAVING SCHOOL (indicate all that apply
):
___ For Employment ___ Low or failing grades
___ Financial Reasons ___ Not attending classes
Explain ____________________________ ___ Not interested in school
___ Family/Personal Obligations ___ Pr
oblems adjusting to school demands
___ Child Car
e Explain _______
______________________
___ Mar
riage ___ Met academic goals (pre-pr
ogram, degree)
___ Transportation ___ Instructor Conflict
___ No famil
y support to stay in school Explain _______
______________________
___ Ot
her _______________________ ___ Transferring
___ Illness or Medical Treatment To ? __
_____________________________
___ Re
sponsibilities due to pregnancy ___ Discipline/Conduct Issues
___ Other _________
______________ ___ Other (Not listed)
___ Join the Military Specify _____________________________
Comment(s):___________________________________________________________________________________________
______________________________________________________________________________________________________
STUDENT’S FUTURE PLANS
Return to MSU Billings ___ Seek Job Training
Transfer to another institution ___ Find Employment
Go to Gradu
ate School ___ Other ______________________________
Do not plan to finish my education
IMPORTANT NOTE: REFUND OF TUITION AND FEES SHALL BE MADE ACCORDING TO MONTANA BOARD OF REGENT
POLICY AS STATED IN THE CURRENT UNIVERSITY CATALOG. REFUNDS ARE CALCULATED BASED UPON THE DATE
THIS FORM IS INITIATED WITH THE MSU BILLINGS ADVISING & CAREER SERVICES OFFICE.
We recommend you thoroughly check into the academic (grading), financial aid (loans, grants, scholarships), and refund deadlines/dates/and
procedures before finalizing your request to withdraw from MSU Billings.
All legal means will be used to collect any unpaid loans. By signing below the student agrees to reimburse the fees of any collection agency,
which may be based on a percentage at a maximum of 33% of the debt, and all other expenses, including reasonable attorneys’ fees the
University incurs in such collection efforts.
SIGNATURES REQUIRED FROM THE OFFICES LISTED BELOW:
___________________
______________________________ ___________________________________________________
Student’s Signature Date Advising & Career Services (McMullen – 1
st
floor) Date
___________________
______________________________ ___________________________________________________
Business Services (McMullen – Basement) Date Financial Aid (McMullen – 1
st
floor) Date
___________________
______________________________ ___________________________________________________
Registrar’s Office (McMullen – 1
st
floor) Date Form Returned to Registrar’s Office
click to sign
signature
click to edit
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