Official Withdrawal Form - Northwood University Forms

Student Name(Required)

Student ID #(Required)

Permanent Mailing Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone(Required)

Reason for Withdrawal:(Required)

Do you have plans to return to Northwood University in the future?(Required)

Yes

When?(Required)

Are your parents aware of your decision to withdraw from school?(Required)

Yes

Are you requesting a refund of all money due to you?(Required)

Yes

Student Signature(Required)

By inputting your name above, you are verifying that the statements and information provided are true and correct, and you are attesting to the validity of all contents within this electronic submission. By clicking on the submit button, you are deemed to have electronically signed this statement.

Date(Required)

Exit Interviewer(Required)

Date(Required)

DEPARTMENTAL SIGNATURES:

To be filled out after submission.

Financial Aid

Business Office

Library

Student Services

International Student Advisor

Resident?

Yes

Has the Housing Director been notified?

Yes

Has housing been cleared?

Yes

Campus Room #

Final Housing Date:

Final Meal Date:

FOR OFFICE USE ONLY

Withdrawal Type

STUDENT BEGINS OFFICIAL WITHDRAWAL PROCESS

OTHER OFFICIAL NOTIFICATION

UNOFFICIAL/ NO NOTIFICATION

SPECIAL CIRCUMSTANCES

For Withdrawal Type 2, 3, or 4 on (Date) it was determined that the student left the institution. How Determined:

Determined Date

Date for the question above.

Date last attended:

Official Withdrawal Date

Registrar Signature

Date

Academic Dean Signature

Date