Withdrawal Petition
Effective: 02/06/2012
APPROVED
DENIED
NO ACTION
ACTION POSTPONED
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Date
Date
Date
Date
No serious compelling reason
Note: _______________________
Note: ____ ___________________
No documentation for claim
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Print Name & Title
Signature/ Date
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First Name MI
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Date of Birth
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City State Zip Code
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LACCD Email Address
I am petitioning to withdraw from class(es):
Winter
1. I took these classes during the:
2. I would like the withdrawal(s) recorded on my transcript:
3. and I would like:
Fall
With a “W”
Fees Waived
Section #
Course Title and Description
Section #
Course Title and Description
1
4
2
5
3
6
Student Signature
Date
Student Name (Please Print)
PETITION TO WITHDRAW FROM CLASS (ES)
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Last Name
____________________________________________________
Student Identification Number
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Street Address
_________________________________________________________
Telephone Number
Spring
Without a “W”
A refund of fees
Summer
20 __ __
With an “EW”
(An EW does not
waive or refund
fees)
click to sign
signature
click to edit
Withdrawal Petition
Effective: 02/06/2012
Statement
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