DIRECTIONS: WITHDRAWAL FORM Submit the form to Financial …

1. Semester/Year:

WITHDRAWAL FORM

DIRECTIONS:

Complete items 1-16 and print out or save a copy of the form

for your records. Submit the form to Financial Aid for approval then take to Admissions and Records on your campus. The date received by the Admissions & Records office is the official date of withdrawal.

2. Student ID:

3. Phone:

4. Last Name:

5. First Name:

6. Street Address:

10. Select one:

Withdrawal from all courses

11. List course information below:

Instructor's

Name

CRN

7. City:

8. State:

Withdrawal from one or more courses

9. Zip:

Course Abbreviation & Number

Credit Hours

For Office Use Only

Grade

Last Date

(W or WF)

of Attendance

12. Are you receiving Veterans?: Yes

No

Financial Aid? Yes

No

13. Are you an international student on an (F-1/M-1) visa? Yes No

If yes, please see international student advisor (ISA)

14. Reason for withdrawal: OFFICE USE ONLY: Withdrawal Code

15. Date:

ISA Signature 16. Student Signature:

Initials

Entry Date

Financial Aid Advisor Signature

Date

The Technical College System of Georgia and GPTC do not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, disabled veteran, veteran of the Vietnam Era, or citizenship status (except in those special circumstances permitted or mandated by law).

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