Registrar's office
First Name: Last Name: ID # (9-digit): Box #: Email:
Course Code: Section: Course Title:
Year: Term:
Reason for Withdrawal:
Academic Program: --Select--UndergraduateDegree CompletionGraduate - MDivGraduate - Other
This withdrawal changes my active academic credit load from From: to: .
Fee: $10
Student's Signature: Date:
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