Request to Withdraw Enrollment
Use this form to permanently request withdrawal from the MD program.
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
*
0/400
Are you transferring Medical Schools?
*
No
Yes
Please indicate the name of the school you are transferring to
*
While enrolled at UHSA, did you fail any classes or retake any exams?
*
Yes
No
Student Email
*
example@uhsa.edu.ag
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: