Permanent Home Address City State Zip
Phone_____________________________________ Personal Email____________________________________________
Program of Study/Major____________________________________________________ Current Semester____________________
Please choose the statement that best describes the reasoning for your withdrawal from MVCC.
Academic Problems (A)
Change in Career Plans (C)
Employment Opportunity (E)
Financial Problems (F)
Illness (personal or family) (I)
Leaving the area (L)
Military Service (M)
Medical Leave of Absence (MLA)
Problems at home (P)
Personal Temporary setback (Q)
Relaves (family problems) (R)
Sickness in family (S)
Transfer to another college (T)
Conict between job and college (Y)
Oce only: Death (D)
Other (O): ________________________________________________________
Please read and inial each line.
I understand that if I withdraw from classes and I do not aend over 60% of classes for the semester, my nancial aid will be adjusted based on my
last day of aendance. Financial Aid will be adjusted and I may owe money to Mohawk Valley Community College and the balance in my account
will need to be paid by me immediately.
I understand that withdrawing from the college may impact my future eligibility to receive nancial aid.
I understand that if I fail to make arrangement to pay the balance, my account will go into collecons. I will be responsible for the amount I owe to
MVCC and any other fees associated with the collecon of this debt.
I understand a hold will be placed on my account that may prevent the release of my transcript and the ability to register for future classes. I am
responsible to pay my debts including charges for tuion, fees, books, housing, library nes, athlec equipment, meal plans, etc. Transcripts will not
be released unl all debt is sased.
I understand that no grades will be recorded on my academic record if I submit my withdrawal before the end of the third week of classes (for a full
semester course). If the withdrawal is submied aer the census date and before the last day to withdraw, I will be assigned a grade of “W”.
Deadlines for courses with other duraons will be prorated (see academic calendar at mvcc.edu). Faculty will assign grades according to the fulll-
ment of course requirements when students do not ocially withdraw from the college
Note: The Vice President for Learning and Academic Aairs or designee may grant excepons to this policy in special circumstances.
_______________________________ Date___________ Coach ________________________ Date__________
s Education Service: Students receiving VA Benefits/DOD Funding: ____________________________________ Date___________
: Students be ready to leave campus once the withdrawal is processed. ______________________________Date__________
Sta Signature Date Eecve Withdrawal Date
Director of Holisc Student Support Date Eecve Withdrawal Date
OFFICE USE ONLY