Name: __________________________________________ CCSU ID Number: ___________________
Last First Middle
Address: _______________________________________ Effective Semester:
Street and Number
_______________________________________ Today’s Date:
City State Zip
University Withdrawal Form
Reason for Withdrawal: __________________________________________________________________________
Graduate Students: Are you withdrawing completely from the University and Program (circle one): YES NO
If no, then only use this form if you are withdrawing from all
of the courses you are currently enrolled in for the semester.
University Withdrawal is allowed no later than four weeks before the last day of the final examination period.
Withdrawals after this date will be permitted only under extenuating circumstances and will require consultation
and approval of the Academic Dean and the Registrar.
It is the responsibility of the student to contact the appropriate offices below to ensure proper withdrawal:
If you have Financial Aid
, please contact the Financial Aid Office, Memorial Hall (860-832-2200)
If you participate in the University-billed Sickness Insurance plan, your coverage under the plan may be affected.
Please contact the Bursar’s Office, Memorial Hall 104 (860-832-2010) to discuss your coverage.
If you live in a University Residence Hall, contact Residence Life, Barrows Hall 120 (860-832-1660)
If you receive Veterans Benefits, contact Veterans Affairs, Davidson Hall 107 (860-832-2838)
If you are taking a Leave of Absence to Study Abroad, contact the Center for International Education and indicate
the name of the program or university that is sponsoring the study: ______________________________
If you are a Student Athlete
, approval is required if you fall below 12 credits:
Athletic Compliance Officer: ______________________________________
(All Student Athletes must maintain Full Time status and be actively enrolled in at least 12 credits. Withdrawal below 12 credits will affect
eligibility to practice and compete.)
In the withdrawal process, I promise to pay Central Connecticut State University, its agents or contractors, any indebtedness which I have incurred.
Additionally, I realize a withdrawal status may affect certain federal and state benefits, various financial aid programs, loans, scholarships, and
social security benefits. Satisfactory Academic Progress requirements must be met for continued financial aid eligibility. Exit interviews are
required of all recipients of student loans.
__________________________________________ _________________________________
Student’s Signature Date
_______________________________________ _______________________________
Registrar Date
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University Leave of Absence (Undergraduate Students Only)
A Leave of Absence (LOA) is a period of separation from CCSU for up to two consecutive semesters. During this time a
student maintains his/her matriculation and is entitled to return to CCSU. Please note: a University LOA is not a federally
approved LOA and could impact the grace period for student loan repayment.
My semester of anticipated return to CCSU is: __________________________________________________
__________________________________________ _________________________________
Student’s Signature Date
Withdrawal Form Must Be Returned to the Office of the Registrar, Davidson Hall, Room 116
1615 Stanley Street, New Britain, CT 06050. Fax: 860-832-2250
Rev. 10/12
