NAME STUDENT ID
Last Name First Middle Required
ADDRESS CITY STATE ZIP
PHONE (H) (W) (C)
I am petitioning for classes for (check one): FALL SPRING SUMMER YEAR:
Did you receive financial aid for the term you are petitioning? Yes No
(If yes, the box below must be completed or your petition will be returned to you.)
Century College is a member of Minnesota State. We are an affirmative action, equal opportunity employer and educator.
This document can be available in alternative formats to individuals with disabilities by calling 651.773.1745 or emailing access.center@century.edu. 5/20
REFUND OR LATE WITHDRAWAL PETITION
Return Form to:
Business Office
West Campus, Room 2340
3300 Century Avenue North
White Bear Lake, MN 55110
I am requesting: Withdrawal after the deadline Refund (or reversal of charges) after the deadline
I am petitioning for: ALL classes in this term ONLY THE FOLLOWING CLASSES (list below).
My petition request is based on the following (check one):
Injury/Illness (medical documentation from a doctor, clinic, or hospital is required)
Death of Family Member (spouse, parent, child or sibling)
College Error
Other
NOTE: Lack of funds, employment issues, change in marital status, child care issues, transportation issues, lack of knowledge of college
policy, failure to correctly process web registration activity, dissatisfaction with instructor and/or course, or failure to follow prerequisites
or placement credits are not grounds for a late withdrawal or a tuition refund/reversal of charges.
Explain your request and the reason for your petition. (Attach additional pages if necessary, as well as supporting documentation.)
Student Signature Date
ALL DECISIONS BY APPEALS COMMITTEE ARE FINAL
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Recommendation: You may obtain a recommendation from faculty, advisor, counselor, etc., to support your petition.
FINANCIAL AID RECIPIENTS: Dropping a class late or withdrawing from all your classes may result in your need to repay funds
disbursed to you. Visit the Financial Aid Office to determine your liability. If your petition is approved, you will be notified and required
to repay financial aid before the petition will be processed.
I have visited the Financial Aid Office and determined I will have no liability.
The Financial Aid Office has determined my liability to be approximately $
FA Use Only:
Initials:
Date:
