MONTANA STATE UNIVERSITY BILLINGS
REQUEST FOR WITHDRAWAL
Student’s Name________________________________________________________________________________
(LAST) (FIRST) (MIDDLE)
ID #_____________________________________________ Phone #____________________________________
Email Address:________________________________________________________________________________
Mailing Address: ______________________________________________________________________________
City: ___________________________________________ State: ______________ Zip: _____________________
Term/Year Withdrawing From: Fall Spring Summer Year _______________________
Last Date Attended Classes
(MO/DAY/YEAR): __________________________________________________________
REASON FOR LEAVING SCHOOL (indicate all that apply):
___ For Employment ___ Low or failing grades
___ Financial Reasons ___ Not attending classes
Explain ____________________________ ___ Not interested in school
___ Family/Personal Obligations ___ Problems adjusting to school demands
___ Child Care Explain _____________________________
Marriage ___ ___ Met academic goals (pre-program, degree)
___ Transportation ___ Instructor Conflict
___ No family support to stay in school Explain _____________________________
___ Other _______________________ ___ Transferring
___ Illness or Medical Treatment To ? _______________________________
___ Responsibilities due to pregnancy ___ Discipline/Conduct Issues
___ Other _______________________ ___ Other (Not listed)
___ Join the Military Specify _____________________________
Comment(s):___________________________________________________________________________________________
______________________________________________________________________________________________________
STUDENT’S FUTURE PLANS
___ Return to MSU Billings ___ Seek Job Training
___ Transfer to another institution ___ Find Employment
___ Go to Graduate School ___ Other ______________________________
___ Do not plan to finish my education
IMPORTANT NOTE: REFUND OF TUITION AND FEES SHALL BE MADE ACCORDING TO MONTANA BOARD OF REGENT
POLICY AS STATED IN THE CURRENT UNIVERSITY CATALOG. REFUNDS ARE CALCULATED BASED UPON THE DATE
THIS FORM IS INITIATED WITH THE MSU BILLINGS ADVISING & CAREER SERVICES OFFICE.
We recommend you thoroughly check into the academic (grading), financial aid (loans, grants, scholarships), and refund deadlines/dates/and
procedures before finalizing your request to withdraw from MSU Billings.
All legal means will be used to collect any unpaid loans. By signing below the student agrees to reimburse the fees of any collection agency,
which may be based on a percentage at a maximum of 33% of the debt, and all other expenses, including reasonable attorneys’ fees the
University incurs in such collection efforts.
SIGNATURES REQUIRED FROM THE OFFICES LISTED BELOW:
_________________________________________________ ___________________________________________________
Student’s Signature Date Advising & Career Services (McMullen – 1
st
floor) Date
_________________________________________________ ___________________________________________________
Business Services (McMullen – Basement) Date Financial Aid (McMullen – 1
st
floor) Date
_________________________________________________ ___________________________________________________
Admissions and Records (McMullen – 1
st
floor) Date Form Returned to Admissions and Records
