3050 Martin Luther King, Jr. Drive Phone: (318) 670-9229
Shreveport, Louisiana 71107 FAX: (318) 670-6344
SUSLA Student ID#:
This is to document the “Administrative Withdrawal or Deletion” of the student referenced above from the following
course(s) for the specified semester.
Effective Term: Year Semester: Fall Spring Summer LPN
This action is requested due to:
Check the appropriate reason below:
Academic (This is an administrative withdrawal request. When processed, a “W” grade will be posted to the record.)
(Academic Reason Only)
Fiscal (This is an administrative deletion request. When processed, all charges and courses will be deleted from the record.)
Reason for Administrative Drop Request
NOTE: Please attach a copy of the student’s course schedule if this request is for more than two courses.
Check this box if this is a request to have ALL courses administratively dropped.
Judicial (This is an administrative withdrawal request. When processed, a “W” grade will be posted to the record.)
NOTE: All reasons require all signatures. Upon receipt in the Registrar’s Office, a copy of this form will be forwarded to the Office of Financial Aid and Business Office.
Requestor’s Signature/Date Academic Dean’s Signature/Date
Approve Disapprove Approve Disapprove
Vice Chancellor for Academic Affairs’ Signature/Date Chief Finance Officer’s Signature/Date
Check this box if this is a request to have the student withdrawn from ALL courses.
Records and Registration
Administrative Withdrawal/Deletion Request
RO: Administrative Withdrawal/Deletion:Revised: 07/14:07/15:07/16:07/17:08/19-LR
Registrar’s Office Use Only