[ { "page": 1, "items": [ { "page": 1, "type": "FIGURE", "location": { "l": 48, "t": 720, "r": 132.72, "b": 635.28 }, "text": "", "reading_order": 0 }, { "page": 1, "type": "TITLE", "location": { "l": 222.24, "t": 718.32, "r": 427.92, "b": 700.08 }, "text": "Official Withdrawal Form", "reading_order": 1, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 140.4, "t": 687.12, "r": 513.6, "b": 673.92 }, "text": "Student signature and date: ___", "reading_order": 2 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 297.617, "t": 697.266, "r": 514.685, "b": 675.266 }, "text": "Student Signature and Date", "field_kind": "text", "label": "Student Signature and Date", "pdf_field_name": "Student Signature and Date", "pdf_field_type": "Text", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 327.84, "t": 673.92, "r": 498.24, "b": 662.4 }, "text": "Signature Date", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 139.44, "t": 651.36, "r": 517.92, "b": 639.12 }, "text": "
\"Image\"
\n", "reading_order": 5 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 204.24, "t": 658.32, "r": 374.28, "b": 641.04 }, "text": "Student Name", "field_kind": "text", "label": "Student Name", "pdf_field_name": "Student Name", "pdf_field_type": "Text", "reading_order": 6 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 416.28, "t": 658.32, "r": 516.24, "b": 641.04 }, "text": "CWID", "field_kind": "text", "label": "CWID", "pdf_field_name": "CWID", "pdf_field_type": "Text", "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 58.08, "t": 630.48, "r": 119.52, "b": 606.96 }, "text": "Student signature and date: ___", "reading_order": 8 }, { "page": 1, "type": "TEXT", "location": { "l": 139.44, "t": 628.08, "r": 514.56, "b": 604.32 }, "text": "Cij\n\nHome Address: Street City State Zip", "reading_order": 9 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 207, "t": 635.28, "r": 517.08, "b": 618 }, "text": "Home Address", "field_kind": "text", "label": "Home Address", "pdf_field_name": "Home Address", "pdf_field_type": "Text", "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 52.32, "t": 606.24, "r": 110.64, "b": 595.2 }, "text": "OFFICE OF\nStudent Name: ___ CWID: ___", "reading_order": 11 }, { "page": 1, "type": "TEXT", "location": { "l": 45.12, "t": 594.24, "r": 132.96, "b": 582.96 }, "text": "THE REGISTRAR\nHome Address: ___\nStreet City State Zip", "reading_order": 12 }, { "page": 1, "type": "TEXT", "location": { "l": 48.48, "t": 593.76, "r": 519.84, "b": 581.76 }, "text": "Term:_____", "reading_order": 13 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 325.56, "t": 601.2, "r": 515.64, "b": 583.92 }, "text": "Term", "field_kind": "text", "label": "Term", "pdf_field_name": "Term", "pdf_field_type": "Text", "reading_order": 14 }, { "page": 1, "type": "TEXT", "location": { "l": 138, "t": 594, "r": 288.48, "b": 581.76 }, "text": "Home Phone: (___) ___", "reading_order": 15 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 200.28, "t": 601.2, "r": 220.32, "b": 583.92 }, "text": "Area Code Home Phone", "field_kind": "text", "label": "Area Code Home Phone", "pdf_field_name": "Area Code Home Phone", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 226.08, "t": 601.2, "r": 286.08, "b": 583.92 }, "text": "Home Phone", "field_kind": "text", "label": "Home Phone", "pdf_field_name": "Home Phone", "pdf_field_type": "Text", "reading_order": 17 }, { "page": 1, "type": "TEXT", "location": { "l": 44.64, "t": 582.96, "r": 134.64, "b": 571.92 }, "text": "Phone: 502-597-6340", "reading_order": 18 }, { "page": 1, "type": "TEXT", "location": { "l": 44.64, "t": 570.96, "r": 133.44, "b": 559.2 }, "text": "Fax: 502-597-6239\nHome Phone: (____) _____", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 49.68, "t": 571.2, "r": 523.68, "b": 558.48 }, "text": "Email address:_____", "reading_order": 20 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 190.529, "t": 580.381, "r": 208.069, "b": 558.381 }, "text": "Area Code Cell Phone", "field_kind": "text", "label": "Area Code Cell Phone", "pdf_field_name": "Area Code Cell Phone", "pdf_field_type": "Text", "reading_order": 21 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 208.333, "t": 578.758, "r": 285, "b": 561.478 }, "text": "Cell Phone", "field_kind": "text", "label": "Cell Phone", "pdf_field_name": "Cell Phone", "pdf_field_type": "Text", "reading_order": 22 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 356.64, "t": 577.92, "r": 521.64, "b": 560.64 }, "text": "Email address", "field_kind": "text", "label": "Email address", "pdf_field_name": "Email address", "pdf_field_type": "Text", "reading_order": 23 }, { "page": 1, "type": "TEXT", "location": { "l": 139.92, "t": 570.96, "r": 286.56, "b": 558.96 }, "text": "Cell Phone: (___) ___", "reading_order": 24 }, { "page": 1, "type": "TEXT", "location": { "l": 86.88, "t": 535.68, "r": 515.28, "b": 430.56 }, "text": "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.", "reading_order": 25 }, { "page": 1, "type": "TEXT", "location": { "l": 87.36, "t": 420.72, "r": 473.76, "b": 409.2 }, "text": "The student will be responsible for any outstanding balance. Withdrawal does not cancel a bill.", "reading_order": 26 }, { "page": 1, "type": "TEXT", "location": { "l": 87.6, "t": 397.92, "r": 519.84, "b": 386.64 }, "text": "I have read this statement and understand it. Student's initials: _____ Date: _____", "reading_order": 27 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 341.16, "t": 405.36, "r": 401.28, "b": 388.08 }, "text": "I have read this statement and understand it. Student’s initials", "field_kind": "text", "label": "I have read this statement and understand it. Student’s initials", "pdf_field_name": "I have read this statement and understand it Students initials", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 427.92, "t": 405.36, "r": 518.04, "b": 388.08 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date", "pdf_field_type": "Text", "reading_order": 29 }, { "page": 1, "type": "TEXT", "location": { "l": 87.6, "t": 374.64, "r": 167.52, "b": 364.08 }, "text": "Are you a veteran?", "reading_order": 30 }, { "page": 1, "type": "TEXT", "location": { "l": 87.12, "t": 374.4, "r": 470.88, "b": 363.6 }, "text": "Yes _____ No _____", "reading_order": 31 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 331.68, "t": 379.925, "r": 391.68, "b": 365.16 }, "text": "Yes", "field_kind": "text", "label": "Yes", "pdf_field_name": "Yes", "pdf_field_type": "Text", "reading_order": 32 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 418.92, "t": 379.087, "r": 473.88, "b": 365.16 }, "text": "No", "field_kind": "text", "label": "No", "pdf_field_name": "No", "pdf_field_type": "Text", "reading_order": 33 }, { "page": 1, "type": "TEXT", "location": { "l": 87.12, "t": 363.84, "r": 245.52, "b": 352.32 }, "text": "Are you receiving veteran's benefits?", "reading_order": 34 }, { "page": 1, "type": "TEXT", "location": { "l": 88.56, "t": 362.88, "r": 474.24, "b": 352.56 }, "text": "Yes _____ No _____", "reading_order": 35 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 331.56, "t": 364.44, "r": 391.56, "b": 353.52 }, "text": "Yes", "field_kind": "text", "label": "Yes", "pdf_field_name": "Yes_2", "pdf_field_type": "Text", "reading_order": 36 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 418.8, "t": 364.44, "r": 473.76, "b": 353.52 }, "text": "No", "field_kind": "text", "label": "No", "pdf_field_name": "No_2", "pdf_field_type": "Text", "reading_order": 37 }, { "page": 1, "type": "TEXT", "location": { "l": 87.84, "t": 350.88, "r": 475.44, "b": 339.12 }, "text": "Do you plan to pre-register for the next semester? Yes _____ No _____", "reading_order": 38 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 331.56, "t": 352.8, "r": 391.56, "b": 341.52 }, "text": "Yes", "field_kind": "text", "label": "Yes", "pdf_field_name": "Yes_3", "pdf_field_type": "Text", "reading_order": 39 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 418.8, "t": 352.8, "r": 473.76, "b": 341.52 }, "text": "No", "field_kind": "text", "label": "No", "pdf_field_name": "No_3", "pdf_field_type": "Text", "reading_order": 40 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 88.44, "t": 318, "r": 550.56, "b": 300.72 }, "text": "For use by the Office of the Registrar – Do not write below this line", "field_kind": "text", "label": "For use by the Office of the Registrar – Do not write below this line", "pdf_field_name": "For use by the Office of the Registrar Do not write below this line", "pdf_field_type": "Text", "reading_order": 41 }, { "page": 1, "type": "TEXT", "location": { "l": 87.36, "t": 299.52, "r": 361.2, "b": 286.08 }, "text": "For use by the Office of the Registrar - Do not write below this line.", "reading_order": 42 }, { "page": 1, "type": "TEXT", "location": { "l": 88.08, "t": 278.16, "r": 242.88, "b": 267.36 }, "text": "Term: _____ Reason(s) for withdrawal: _____", "reading_order": 43 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 112.8, "t": 286.2, "r": 160.92, "b": 268.92 }, "text": "Term", "field_kind": "text", "label": "Term", "pdf_field_name": "Term_2", "pdf_field_type": "Text", "reading_order": 44 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 240.24, "t": 286.2, "r": 516.12, "b": 268.92 }, "text": "Reason(s) for withdrawal", "field_kind": "text", "label": "Reason(s) for withdrawal", "pdf_field_name": "Reasons for withdrawal", "pdf_field_type": "Text", "reading_order": 45 }, { "page": 1, "type": "TEXT", "location": { "l": 87.6, "t": 260.4, "r": 495.12, "b": 248.88 }, "text": "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.", "reading_order": 46 }, { "page": 1, "type": "TEXT", "location": { "l": 88.08, "t": 242.16, "r": 446.4, "b": 230.16 }, "text": "This form has been completed without the student's signature? Yes _____ No _____", "reading_order": 47 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 305.162, "t": 254.614, "r": 354.559, "b": 232.614 }, "text": "Yes_4", "field_kind": "text", "label": "Yes_4", "pdf_field_name": "Yes_4", "pdf_field_type": "Text", "reading_order": 48 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 376.56, "t": 250.2, "r": 444.6, "b": 232.92 }, "text": "No", "field_kind": "text", "label": "No", "pdf_field_name": "No_4", "pdf_field_type": "Text", "reading_order": 49 }, { "page": 1, "type": "TEXT", "location": { "l": 87.84, "t": 224.4, "r": 447.84, "b": 193.92 }, "text": "Reason: ___ student refused to complete form ___ online or virtual student other: ___", "reading_order": 50 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 118.44, "t": 232.2, "r": 158.52, "b": 214.92 }, "text": "Reason [1]", "field_kind": "text", "label": "Reason [1]", "pdf_field_name": "Reason 1", "pdf_field_type": "Text", "reading_order": 51 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 286.56, "t": 232.2, "r": 370.56, "b": 214.92 }, "text": "student refused to complete form", "field_kind": "text", "label": "student refused to complete form", "pdf_field_name": "student refused to complete form", "pdf_field_type": "Text", "reading_order": 52 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 117.96, "t": 214.2, "r": 158.04, "b": 196.92 }, "text": "Reason [2]", "field_kind": "text", "label": "Reason [2]", "pdf_field_name": "Reason 2", "pdf_field_type": "Text", "reading_order": 53 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 180.24, "t": 214.2, "r": 448.44, "b": 196.92 }, "text": "other", "field_kind": "text", "label": "other", "pdf_field_name": "other", "pdf_field_type": "Text", "reading_order": 54 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 160.92, "t": 196.2, "r": 448.92, "b": 178.92 }, "text": "Completed by (name", "field_kind": "text", "label": "Completed by (name", "pdf_field_name": "Completed by name", "pdf_field_type": "Text", "reading_order": 55 }, { "page": 1, "type": "TEXT", "location": { "l": 88.32, "t": 188.16, "r": 161.04, "b": 176.88 }, "text": "Completed by (name): ___", "reading_order": 56 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 141.36, "t": 178.2, "r": 241.44, "b": 160.92 }, "text": "Date completed", "field_kind": "text", "label": "Date completed", "pdf_field_name": "Date completed", "pdf_field_type": "Text", "reading_order": 57 }, { "page": 1, "type": "TEXT", "location": { "l": 88.56, "t": 170.4, "r": 143.76, "b": 159.6 }, "text": "Date completed:", "reading_order": 58 }, { "page": 1, "type": "TEXT", "location": { "l": 88.32, "t": 133.68, "r": 160.32, "b": 123.36 }, "text": "Form Revised 2/2009", "reading_order": 59 }, { "page": 1, "type": "FIGURE", "location": { "l": 473.28, "t": 114.96, "r": 531.6, "b": 99.12 }, "text": "", "reading_order": 60 } ] } ]