|
Student Name:
RU ID:
Major:
Local Address:
Phone:
Term:
Index
Number |
Course Prefix
& Number |
Section
# |
Course Title |
Instructor Signature |
| |
|
|
|
|
Advisor Signature:
Date:
Student Signature:
Date:
Are you: An Athlete
Yes
No
Receiving Veteran's Benefits
Yes
No
As a result of this withdrawal I will be enrolled in
hours.
Data entry date:
Entered by:
Note: Students are responsible for any effect their withdrawal may have on eligibility for graduation, GPA, etc. Students with questions should consult with their advisor.
Distribution: Registrar, Instructor, Advisor, Student.
RG 16
Rev. 1/00
Rev. 3/4/04
Rev. 10/16/06
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