Name___________________________________________________________M# ________________________
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)
Hospitalizaon (H)
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)
Relaves (family problems) (R)
Sickness in family (S)
Transfer to another college (T)
Transportaon (X)
Conict between job and college (Y)
Oce only: Death (D)
Other (O): ________________________________________________________
 Please read and inial each line.
I understand that if I withdraw from classes and I do not aend over 60% of classes for the semester, my nancial aid will be adjusted based on my
last day of aendance. 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 collecons. I will be responsible for the amount I owe to
MVCC and any other fees associated with the collecon 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 tuion, fees, books, housing, library nes, athlec equipment, meal plans, etc. Transcripts will not
be released unl all debt is sased.
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 submied aer the census date and before the last day to withdraw, I will be assigned a grade of W”.
Deadlines for courses with other duraons will be prorated (see academic calendar at mvcc.edu). Faculty will assign grades according to the fulll-
ment of course requirements when students do not ocially withdraw from the college
Note: The Vice President for Learning and Academic Aairs or designee may grant excepons 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 Eecve Withdrawal Date
LATE WITHDRAWAL_______________________________________________________________________________________________________________
Director of Holisc Student Support Date Eecve Withdrawal Date
Reason for Withdrawal