Request to Withdraw Enrollment

Request to Withdraw Enrollment

Use this form to permanently request withdrawal from the MD program.
Student Name*

First NameMiddle NameLast Name
Student ID Number*
Program*

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

MonthDayYear
Date
For the following reason*
Student Email*
example@uhsa.edu.ag
Phone Number*
Please enter a valid phone number.
Signature*

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I understand that any 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.
Date

MonthDayYear
Date
Should be Empty: