For Office Use Only
Instructor's Course Abbreviation Credit Grade Last Date
Name CRN & Number Hours (W or WF) of Attendance
Complete items 1-16 and print out or save a copy of the form
for your records. Submit the form to Financial Aid for
approval then take to Admissions and Records on your
The date received by the Admissions & Records
office is the official date of withdrawal.
1. Semester/Year:
2. Student ID:
3. Phone:
4. Last Name: 5. First Name:
6. Street Address: 7. City: 8. State: 9. Zip:
10. Select one:
Withdrawal from all courses Withdrawal from one or more courses
11. List course information below:
12. Are you receiving Veterans?:
Yes No
Financial Aid?
Yes No
13. Are you an international student on an (F-1/M-1) visa?
Yes No
If yes, please see international student advisor (ISA)
14. Reason for withdrawal:
ISA Signature
15. Date:
The Technical College System of Georgia and GPTC do not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age, political affiliation or
belief, genetic information, disabled veteran, veteran of the Vietnam Era, or citizenship status (except in those special circumstances permitted or mandated by law).
Withdrawal Code
Entry Date
Financial Aid Advisor Signature Date
16. Student Signature:
Print Form