JMU Course Withdrawal Form

JMU Course Withdrawal Form
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
Faculty and Department*

FacultyDepartment
GPA and Cumulative GPA*

GPACumulative GPA
Active Semester*

FallSpring
Course Name, Course Code, Section Number, Credit Hours*
Reasons for withdrawal:*
Last Date of Attendance*

MonthDayYear
Date
Date of Determination

MonthDayYear
Date
I understand that even though I withdraw, I am obligated to pay all charges on my student account. Additionally, I understand that students who
receive financial aid and withdraw from the institution will have their financial aid adjusted according to federal regulations. This may leave an
outstanding balance on my student account, and I will be billed for any remaining balance.
Signature*

Clear
Date*

MonthDayYear
Date
FOR OFFICE USE ONLY
Is student receiving financial aid?

YesNo
Is an exit interview required?

YesNo
Financial Aid Counselor's Signature

Clear
Date

MonthDayYear
Date
Cashier's Office:
Student Live on Campus?

YesNo
Student currently on a meal plan?

YesNo
Cashier's Signature

Clear
Date

MonthDayYear
Date
Office of Student Records Processed By:

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: