Request to Withdraw Enrollment

Request to Withdraw Enrollment
Student Name *

First Name Middle Name Last Name
Student ID Number *
Program *

Doctor of Medicine Premedical Sciences
I request to withdraw my enrolment with UHSA on *

Month Day Year
Date
For the following reason *
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
I understand that the refund I am receiving from the University is subject to UHSA Rules and Policies. Furthermore, if I desire to join the university at a future date, I must apply as a new student.
Signature *

Clear
Date

Month Day Year
Date
Should be Empty: