Revised 12/3/2019
*Contact Financial Aid (205-726-2905) for information if you currently have any type of financial assistance*
Date Phone # SU ID
Full Name
Address City, State, Zip
Term withdrawing from: Fall (A) (B) Jan Term Spring (A) (B) Summer 1 Summer 2 Summer 3 14 week summer
Please circle class: FR SO JR SR Grad Divinity Pharmacy Public Health Other
REQUIRED: Last date you attended class(es) in person or on-line
Do you intend to return to Samford University? Yes No If yes, when? ______________________
Are you an international student? Yes No
If yes, signature of International Advisor: ___________________________________________________________________
Are you an athlete? Yes No
If yes, signature of Athletic Student Advisor: ________________________________________________________________
Student Signature: _________________________________ Signature of College Rep.:______________________________
Signature of College or School Rep. (see list below)
A&S or Undeclared Dana Basinger
Arts Cameron Barnes
Business Barbara Cartledge
Divinity Sharon Head
Education-undergraduate Daphne Carr
Education-graduate Marcie Harchuck
Undergrad Nursing Jan Paine
Graduate Nursing Allyson Maddox
Undergrad Pharmacy Jon Parker
Graduate Pharmacy Michael Kendrach
Health Prof. and Pub. Health Marian Carter
Professional Studies Bryan Gill
Reason for withdrawing:
--------------------------------------------------- For Office Use Only ------------------------------------------------------------
Term/Semester Credit: 100% 90% 75% 50% 25% 0%
Term/Semester Credit: 100% 90% 75% 50% 25% 0%
Total Charges:
Amount Refunded:
After obtaining necessary signatures, return the completed form to the Office of the Registrar, 800 Lakeshore Drive,
Birmingham, AL 35229 / fax to 205-726-2908 or print, scan and email to (Karen Rayburn)
Photographed copies of this form are not accepted.
Do not write in this space