Withdrawal Card

Student's ID#:*
Please type the 7 digit student ID
Student's Name:*
Please enter Student's Name as: last name, first name, middle initial
Course to Drop
Provide course prefix, course number, and course section below.
Course Prefix:*
Course Number:*
Course Section:*
Withdrawal initiated by:*
Choosing the Instructor option will prompt for additional information.
Reason for Withdrawal:
Student Means of Notification:
- Phone
- Email
- In Person
Reason for Withdrawal:*
Other Reason
If the instructor's reason is other, briefly explain.
Last Date of Attendance (LA):*
MM slash DD slash YYYY
Current Date:*
MM slash DD slash YYYY
Grade:*
Electronic Signature
By submitting this withdrawal card, I certify to the best of my knowledge that the information given is true and complete. Further, I understand and agree that my electronic signature is the legal equivalent of my manual signature.
Instructor's First and Last Name:*
Instructor's Email Address*
This will be used to send an confirmation email for record keeping purposes.

Course to Drop