Request for Withdrawal
Print Form
Revised 04-15-20
Name: CWID: T
Phone: ( ) -
City State Zip
TCC Email: @tulsacc.edu Semester: (Check One)
Are you requesting to be withdrawn from all of your classes?
Yes No
Fall Spring Summer
List all courses from which you wish to be withdrawn:
Course #
Reason(s) for Withdrawal (Check all that apply)
In response to the extraordinary challenges caused by the novel coronavirus COVID-19, Tulsa Community College continues
to identify and support affected students. Please initial below if your reason for withdrawing is NOT directly or indirectly
related to the COVID-19 pandemic.
___I acknowledge my request to withdraw is not related to COVID-19
Academic Reasons
Dissatisfied with my academic performance
Dissatisfied with the quality of teaching
Dissatisfied with the learning environment
Course level too advanced
Financial Reasons Additional Reasons
Could not obtain sufficient financial aid
Entered the military/deployment
Not enough money to continue
Illness/Life Crisis
Was not able to purchase books
Personal Problems
Moving out of the area
College experience not what I expected
Work related conflict
Initials Student Responsibility
I understand that I am responsible to pay any outstanding financial obligations to TCC.
I understand a “W” or Withdrawal grade will be awarded on my transcript for the courses from which I am
I understand the consequences of withdrawing and I accept that my financial aid status, current or future, may be
Student Signature: Date:
Financial Aid Recipients Only:
Affidavit of Enrollment
For this current semester, I am enrolled and plan to enroll in additional courses that have not yet started. Failure to successfully complete
future classes (including any that may be canceled due to low enrollment) may result in owing funds to TCC.
Student Signature: Date:
Return this form in person to any campus Advisement Office to start the withdrawal process.
Distance Learning Students: When returning by fax or if mailed to any campus Advisement Office:
Include legible copy of a valid Driver’s license or Student ID.
Fax Numbers: Metro 918.595.7320 * Northeast 918.595.8430 * Southeast 918.595.8672 * West 918.595.8118
Office Use Only
Has the student notified the instructor (s) Yes No
Has the student received academic advisement regarding withdrawal? Yes No
Is the student receiving any type of financial aid? Yes No
Advisor Signature:________________________________________________________ Date:
Financial Aid
Student Consequences:
May result in re-payment of all or partial Title IV Funds
May Place Student on Financial Aid Warning
May Place Student on Financial Aid Suspension
Completion Rate: GPA:
Enrolled in upcoming parts of term? Yes No Enrollment Status: Change to WD Yes No
Fin Aid Rep Signature: Date:
Enrollment Services
Enrollment Status Changed Yes No Processed by: Date: