Star ID/Student ID #: _____________
Program/Major: _____________________ Semester:_________
Permanent Mailing Address: ______________________________________________________________
Telephone: ______________________
Do you plan to return at a later date: No Unsure Yes
If so, when? _______________
You will be required to complete an Application upon return. You may be subject to new program requirements
when you re-enroll.
Did you receive any type of financial aid? No Yes If yes, you may be required to repay a portion of
the financial aid you received. Contact the financial aid office if you have questions.
***Are you enrolled in any distance education course(s)? No Yes If yes, you will need to go to your
eServices and withdraw from your courses.
Please be aware that dropping/withdrawing from courses may impact your Satisfactory Academic
Progress status.
Reason(s) for leaving Northland (Check all that apply individual data furnished will be kept confidential):
Academic Military
Campus Social Climate Missed too many classes
Cancellation of Classes Moving *
Child Care Issues Not Ready for College
Courses Not What I Expected Not the Program for Me
Coursework too Difficult Personal Finances
Dissatisfaction with Instruction Personal Reasons
Dissatisfaction with Services Too Far From/Close to Home
Family Issues Transferring to Another College, Please
Financial Aid
Indicate College
Work/Job Offer
*If moving, please indicate your new address if it will be different from your permanent address indicated above.
Is there anything Northland could have assisted you with that would have allowed you to continue your enrollment?
If so, please indicate what would have been helpful:
____________________________________________________ ______________________________
Student Signature Date
____________________________________________________ ______________________________
Advisor/Counseling Office Signature Date
____________________________________________________ ______________________________
Registrar’s Office Signature Date
Northland Community and Technical College is an affirmative action, equal opportunity employer and educator.
This document is available in alternative formats to individuals with disabilities, consumers with hearing or speech disabilities may contact us via their preferred Telecommunications Relay Service by
dialing 711 (toll-free nationwide).
4/7/2020 BGH
click to sign
click to edit
click to sign
click to edit
click to sign
click to edit