OfficialWithdrawalfromCollege
NewburghCampus
1WashingtonCenter,Newburgh,NY12550
MiddletownCampus
115SouthStreet,Middletown,NY10940
(845)341‐4140●registrar@sunyorange.edu
**For Student Services Central
Use Only**
____________ _________
Process Date Initials
Name of Student (Last, First, Middle Initial) Student ID#: A Date:
Address:
City: State: Zip: Phone:
Semester/Year: Fall ___ Winter ____Spring ____ Summer _____Current Program: ____________________
I Intend to Return Yes_____ No _______ Full Time: _____ Part Time ____ Semester: ______ Year: _______
Student Reason For Withdrawing (Check One -- the most prominent)
Employment(New or Change in Hours) Financial Aid (FAFSA Issues)
Military Obligations Family Issues
Personal Financial Issues Health Issues
Relocation Personal Issues
Transportation Issues Transferring to a different college
Academic Issues Other
Drop Course
CRN Subject Course Section Credits Ever Attended Faculty Name
Student’s Signature Date
All Federal Financial Aid recipients who withdraw or stop attending classes in the first 60% of the semester will
have their Federal Financial Aid recalculated (see College Catalog).
Section to be Completed by Faculty Advisor or Academic Advising Office
Degree Seeking Yes No
Faculty Advisor or Academic Advising Office Signature Date
Section to be Completed by Financial Aid Office
Current Financial Aid Recipient or Applicant if (NO) Financial Aid signature not required
Current and/or Former Loan Recipient Yes No
Exit Interview Complete Yes No
Financial Aid Office Date
