Request for Withdrawal - (All Classes)

Viterbo University; 900 Viterbo Drive; La Crosse WI 54601
 
TO BE COMPLETED BY THE STUDENT      (Please complete ALL portions.)
I wish to withdraw from Viterbo University. I have discussed my intentions to withdraw with my advisor or graduate program director.
 
  Student ID Number        Social Security Number  
  First Name    Middle Name 
  Last Name       Birth/Maiden Name  
    
  Home Mailing Address Street      City 
  State     Zip   
  Home Phone, including area code   Email
  Major/Graduate Program    Advisor
  Select Term for Withdrawal   Student Level
 
I am registered in the following course sections. Please drop these courses for me. (List ALL your courses for the semester.)
SubjectNo.Sec.Cr. Title InstructorLast Date of Attendance
(Best approximation)
             
             
             
             
             
             
  Reason for Withdrawal:   I plan to return to Viterbo:
 
Students should contact the business office and financial aid offices for information about withdrawal implications prior to submitting this form.
 
I acknowledge that there may be student billing implications to my withdrawal, even if I do not currently have a balance. No transcript will be issued, nor may I return to Viterbo, until those encumbrances are satisfied.
I acknowledge that there may be financial aid implications to my withdrawal from school.
 If you are living on campus, the Office of Residence Life expects that all students who withdraw during the school year move out of their rooms and apartments within 48 hours of the withdrawal.
 
I understand that by signing this form, I am withdrawing from classes for the semester/term.  If I decide to resume my studies, I must reapply for admissions.
  Student E-Signature   Date: