Withdrawal Form
University Hall. | 2197 S. University Blvd. | Denver, CO 80023-9405 | 303-871-4095 | Fax 303-871-4300 | www.du.edu/registrar
University of Denver ID#
GRADUATE UNDERGRADUATE
Name: __________________________________________________________________
Last First
Phone Number: (_____)_________________ Email Address _________________________________
Term of withdrawal: _______________ Year: _______________
Quarter Semester Interterm
Do you plan to resume your studies at the University of Denver?
Yes No Not sure
Academic Military Assignment Transferring to another University
Career Peace Corps (foreign aid service)
Church Mission Permanent Disability
Financial Personal/Family
Health Social
I understand that, by submitting this form to the Office of the Registrar during the AUTOMATIC WITHDRAWAL period (as
specified in the current academic calendar), I will be withdrawn from all classes for which I am enrolled for the term I have
specified above. When submitting this form AFTER THE AUTOMATIC WITHDRAWAL PERIOD, BUT BEFORE
THE DROP/ADD DEADLINE, a Course Change Request form (drop/add) must be submitted with appropriate instructors’
signatures before the withdrawal will be processed.
I understand that I am responsible for tuition and fees assessed according to the refund schedule in effect on the date that this
form is submitted to the Office of the Registrar as dated by the Office of the Registrar below. I understand that, in the case of
extenuating circumstances, I can appeal tuition and fee charges by submitting a request for medical leave of absence or a formal
tuition appeal.
I understand that my withdrawing from the University will affect my eligibility to remain in student housing, to use campus
facilities and to retain health insurance benefits. My current and future financial aid awards will be affected and I may be liable
for tuition owed as a result of the return of financial aid funds.
Note: Non U.S. citizens who withdraw from the University may jeopardize their immigration status and their ability to remain
in the United States.
Having read this form as well as the WITHDRAWAL INFORMATION SHEET AND CHECKLIST and having
secured appropriate instructor approval when required, I request that I be withdrawn from the University for the term
indicated above.
Student Signature____________________________________________ Date: _________________
For Office Use Only:
Total Credit Hours Dropped: _____ Refund: 100% 75% 50% 0% Date Received: ________________by (Print Name & Title):
Last_________________________________________First______________________________Title__________________________
Signature_____________________________________________ Circle mode of contact if In lieu of form: Phone Email (attach to form)
Date Withdrawal Processed ____________by______________ Title IV updated: ______________by ________________Rev. 07/29/13
