Student Course Withdrawal Request
  1. Please submit a separate form for each course.
  2. First Name(*)
    First Name required.
  3. Middle Name
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  4. Last Name(*)
    Last Name required.
  5. ECC Student ID(*)
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  6. Birth Date(*)
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  7. Home Address
    Please let us know your message.
  8. Your Email(*)
    Request will fail if email address is not given!
  9. Phone(*)
    This number may be called to verify request, it is required.
  10. Best time to call
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  11. Course Prefix(*)
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  12. Course Number(*)
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  13. Course Section(*)
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  14. Course Title(*)
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  15. Instructor(*)
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  16. Attended
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  17. Name of your advisor(*)
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  18. Your Program of Study(*)
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  19. Reason for request(*)
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  20. Please enter the captcha phrase. 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. If you cannot read the phrase, click on the refresh button below the captcha for a new set of characters.
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