Withdrawal / Leave of Absence

Forms received will be processed immediately. Please do not submit in advance of effective date of withdrawal.

* = required

Student Information

First Name*

Middle Name

Last Name*

Birthdate*

UNI*

PID*

Current Program*

Contact Information

Main Address*

Country

Street

City

Region

Postal Code

Email

Phone

Withdrawal / LOA

Withdrawal or Leave of Absence?*

Reason for Withdrawal / LOA*

Effective Date of Withdrawal / LOA*

Effective Term of Withdrawal / LOA

Expected Return Date

Expected Return Term

Are you a Federal Student Aid recipient?*

Please indicate the type of program you participate in:

Are you in University Housing?*

Please provide any other pertinent information: