Withdrawal Grade Form

Withdrawal Grade Form
Student Name
First NameLast Name
Student ID
Program/Major
Course Name
Course Code
Instructor's Name
First NameLast Name
Withdrawal Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Withdrawal
Other
Grade at the Time of Withdrawal
Other
Additional Comments (if any)
I, the undersigned, hereby confirm that I have voluntarily withdrawn from the above-mentioned course. I understand the implications of this withdrawal, including the assigned grade, and have discussed the decision with the instructor.
Student's Signature
Clear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: