Fillable form and take it to Registration & Scheduling (University of Southern Maine)

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BROWSE UNIVERSITY OF SOUTHERN MAINE FORMS

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Office of the Regi
Registration & Scheduling Services
140 Luther Bonney, Portland Campus
107 Bailey Hall, Gorham Campus
TEL (207) 780-5230
TTY (207) 780-5646
FAX (207) 780-5517
registerusm@maine.edu
usm.maine.edu/reg
SEMESTER LEAVE FORM
Instructions: Use this form only if you wish to withdraw from classes for the semester indicated. Complete this
form and take it to Registration & Scheduling Services. If you live on campus, please be sure to inform Resident
Student Services. Be aware that most students are eligible to return without re-application. See the catalog for
details.
When a student withdraws, charges are reduced in accordance with schedules established by the University
of Maine System Board of Trustees. Check the catalog for details. If you are eligible for a refund, reimbursement
will be made within 30 days. Checks are mailed to your permanent address, as maintained by Registration &
Scheduling Services. If payment was made by Bankcard, that card will be credited. After withdrawing for the
semester, you may still owe monies to the University. Check with Student Financial Services for details.
Non-attendance does not constitute notification of intent to apply for leave status. Leave (withdrawal) date
is the date that Registration & Scheduling Services is notified in writing. After the eighth week of classes for spring
or fall semester a grade, to be determined by the instructor, will be assigned for courses withdrawn.
___________________________________
MaineStreet ID # (7 digits)
________________________________________________
NAME
_______________________________________________
_______________________________________________
MAILING ADDRESS
________--________--_________________
TELEPHONE NUMBER
YES NO
Are you receiving VA benefits? ☐ ☐
Are you receiving Financial Aid? ☐ ☐
Did you receive a loan while at USM? ☐ ☐
Do you reside in a USM residence hall? ☐ ☐
_______________________________
Dorm
Have you notified your academic advisor? ☐ ☐
__________________________________________________
Advisor Name
Fall ____ Spring ____ Year ________
(Semester of withdrawal, please check)
Date Completed:_______________
LEVEL:
☐ Undergraduate
☐ Graduate
☐ Law
REASON FOR LEAVING:
☐ Academic
☐ Death in Family
☐ Employment
☐ Financial
☐ Illness ___Self ____Family
☐ Leaving Area
☐ Marriage
☐ Maternity Leave
☐ Military
☐ Personal
☐ Transfer - Internal __________________
☐ Transfer - External _________________
Student Signature: _____________________________________________________ Date Signed:_________________
Student Comments:
________________________________________________________________________________________________________
(Attach separate sheet if more room is needed)
Signature of University Official: _______________________________________ Date Signed:______________________
Registration & Scheduling Services 08/2018
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Completed 24 July 2020

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