Unofficial Withdrawal
  1. This form is used to unofficially withdraw a student from a course.
    ** For Faculty Use Only! **
    Please complete all form fields marked with an (*) asterisk.

  2. Student ID Number
    (Do NOT enter SSN)(*)
    Invalid Input
  3. Student First Name(*)
    Invalid Input
  4. Student Middle Name
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  5. Student Last Name(*)
    Invalid Input
  6. Student Email Address(*)
    Invalid Input
  7. Student Phone Number(*)
    Invalid Input

  8. Instructor Name(*)
    Invalid Input
  9. Instructor Email Address(*)
    Invalid Input
  10. Office Phone Number(*)
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  11. Course Number(*)
    Invalid Input
  12. Course Name(*)
    Invalid Input
  13. Section Number(*)
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  14. Last Day of Attendance(*)
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  15. Notes
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  16. Please enter the captcha phrase below. If you cannot read the phrase, click on the refresh button below the captcha for a new set of characters
    Please enter the captcha phrase below. If you cannot read the phrase, click on the refresh button below the captcha for a new set of characters
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