← Official_Withdrawal_Form.pdf

Rebuilt HTML — PaddleOCR-VL (Baidu)

Semantic HTML reconstructed from the OCR item tree (headings, text, lists, tables, form fields). overlay · view JSON

Semantic Positioned (like PDF)

Page 1 Download HTML

Official Withdrawal Form

Student signature and date: ___

Student Signature and Date

Signature Date

Student Name

CWID

Student signature and date: ___

Cij Home Address: Street City State Zip

Home Address

OFFICE OF Student Name: ___ CWID: ___

THE REGISTRAR Home Address: ___ Street City State Zip

Term:_____

Term

Home Phone: (___) ___

Area Code Home Phone

Home Phone

Phone: 502-597-6340

Fax: 502-597-6239 Home Phone: (____) _____

Email address:_____

Area Code Cell Phone

Cell Phone

Email address

Cell Phone: (___) ___

Students who receive Title IV financial aid Pell Grant, Federal SEOG, Federal Perkins Loan, Federal Direct or PLUS loans and withdraw from the University are subject to the Return of Title IV Funds regulations. Students with funds from any of these programs “earn” their financial aid dollars while enrolled. If a student withdraws prior to completing 60% of a term, a prorated portion of his/her federal financial aid dollars must be considered “unearned” and returned to the federal programs. Unearned financial aid dollars returned to the federal programs could cause students to owe the University a significant amount upon withdrawal. Failure to return aid due back to their federal programs will result in loss of eligibility for federal financial aid assistance. Unpaid delinquent amounts may result in collection procedures.

The student will be responsible for any outstanding balance. Withdrawal does not cancel a bill.

I have read this statement and understand it. Student's initials: _____ Date: _____

I have read this statement and understand it. Student’s initials

Date

Are you a veteran?

Yes _____ No _____

Yes

Are you receiving veteran's benefits?

Yes _____ No _____

Yes

For use by the Office of the Registrar – Do not write below this line

For use by the Office of the Registrar - Do not write below this line.

Term: _____ Reason(s) for withdrawal: _____

Term

Reason(s) for withdrawal

If the student refuses to complete the withdrawal form or is at a distance from the University, someone in the Office of the Registrar will complete the form.

This form has been completed without the student's signature? Yes _____ No _____

Yes_4

Reason: ___ student refused to complete form ___ online or virtual student other: ___

Reason [1]

student refused to complete form

Reason [2]

other

Completed by (name

Date completed

Form Revised 2/2009