University Withdrawal Agreement

University Withdrawal Agreement

This form is to be submitted when it is the student's intent to completely withdraw from Belmont University
Student Name *

First Name Last Name
Belmont ID Number *
This number is B00 followed by six unique digits
Belmont E-mail Address *
Typically: first.last@pop.belmont.edu (please verify before submitting)
Student Cell Phone Number *

Area Code Phone Number
Term in Which You Intend to Withdraw *
Year in Which You Intend to Withdraw *
IMPORTANT NOTE:

If you are withdrawing from the university for the current semester, please be aware of the courses schedule change deadlines and the last day to withdraw for the semester linked HERE.

Please also make note of Student Financial Services' deadlines for any percentage of a tuition refund linked HERE.
Required Information
Do you have a housing assignment for the term in which you intend to withdraw? *
On-Campus Residence
Do you have a meal plan? *
Are you a student athlete? *
Contact your Athletic Academic Coordinator
Are you a recipient of Veteran Education Benefits? *
Contact the VA Education Counselor, Daina Hunter at daina.hunter@belmont.edu
Are you using an F1 Visa? *
Contact the Assistant Director of International Students and Scholars (Office of Global Education)
Are you a recipient of the HOPE Scholarship? *
If you are receiving the Tennessee HOPE Scholarship, withdrawing from the university may discontinue your HOPE Scholarship eligibility. Contact Student Financial Services for information on the appeal process.
Do you receive federal loans/grants (Title IV), state or institutional aid? *
As a Title IV recipient, I understand that in accordance with Federal Regulations, all or a portion of my loans or grants may be removed from my account. In the event funds are removed, I agree to pay any outstanding charges that result from this federal calculation. According to Belmont policy, institutional scholarships and grants may be removed, thus creating additional charges for which I am responsible.
Student Initials to Agree to the Above Statement
Last Date of Course Attendance *

Month Day Year
If you never attended a course, put today's date
Registrar Approval of Last Day of Attendance
Registrar Approval Last Day of Attendance Date

Month Day Year
Date
Reason for Withdrawal *
If "Other" reason is chosen, please provide your specific reason for withdrawing from the university. (Your response will be held in confidence).
Reason for Withdrawal
Students are required to re-apply through the Office of Admissions if absent or not enrolled for a semester. The re-admit process is simple and straight-forward.
Sign Below to Acknowledge the Following Information:
- Refer to the Belmont website and university catalog for the DIFFERENT refund policies and deadlines for tuition, fees, housing, and meal plans.
- I understand that it is my responsibility to follow up with Student Financial Services and Residence Life regarding my account and any balance which may remain due to withdrawing from Belmont.
- If there are charges which I have incurred that have not yet posted to my student account, I understand and agree that I am responsible for these charges.
Signature *

Clear
Should be Empty:

University Withdrawal Agreement

Required Information