Student Withdrawal from CNMI PSS District Request

Date of Withdrawal Request Made*

MonthDayYear

Hour MinutesAM/PM Option

Student Name:*

First NameMiddle NameLast NameSuffix

Student Date of Birth*

MonthDayYear

School Year*

Requested date of last day at current (SY 24-25) school:*

MonthDayYear

Current (SY 24-25) School*

The school that the student is currently attending.

Grade Level at Current (SY 24-25) School*

Please indicate the name of the school district and/or other, the address, phone number, and/or email address where you need the school to send official documents to.

Terms and Agreements

All outstanding obligations to the school must be paid in order for the school to release official certified copies of the student's transcript.
The student's cumulative folder will be given to the parent/guardian after the school uploads the electronic copy of selected documents from the folder and into the student's electronic portfolio.

Parent/Guardian Name:*

PrefixFirst NameMiddle NameLast NameSuffix

Relationship to Student:*

Parent/Guardian Email Address:

example@example.com

Phone Number

Parent/Guardian Signature:*