Withdrawal Form - Adult / Traditional
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1WITHDRAWAL FORM
ADULT/TRADITIONAL
ID#______________
SP___ SU___ FL___ Year: _______
The OFFICIAL date of withdrawal is determined by the date that the first contact is made by the student to initiate the
withdrawal process. Charges and/or refunds to the student’s account and grades are based on this date.
Circle Program:
Adult
Traditional
Receiving VA Benefits: ______ Y ______N
___________________________________________________________________________________
Name
___________________________________________________________________________________
Address
___________________________________________________________________________________
____________________________________________________________
City
State
Zip
Last Data of Attendance
___________________________________________________________________________________
Phone
__________________________________________________________________________________________________________________________________________________________________
Reason for Withdrawal
_________________________________________________________________
Student Signature
Date
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(Official Use Only)
In order for a student to be OFFICIALLY withdrawn from Faulkner University, he/she must clear with each of the following offices:
Adult Students
Traditional Students
________ Adult Students – Advisor
_______ Traditional Students - Student Success
________ VA Coordinator
________ VA Coordinator
________ Library (Charges: ____________)
________ Dean of Students
________Financial Aid (
________ Financial Aid
Adjusted based on last date of attendance)
(Adjusted based on last date of attendance)
________ Student Accounts (Charges :____________)
________ Library (Charges: ____________)
________ Registrar’s Office
________ Instruction Technologist - iPad
(Charges: ___________)
________ Student Accounts - Refunds to account (if any):
(Tuition: ______________Meals: ________________)
(Apt/Dorm: ____________Other :_______________)
________ Registrar’s Office
08/12/2013
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