STUDENT WITHDRAWAL INFORMATION NAME YEAR WVU ID

RYERSON ABORIGINAL STUDENT SERVICES PEER SUPPORT AT RASS
STUDENT ID DUPLICATE CREDENTIAL REQUEST FEE CHARGED
LUBLIN IMIĘ I NAZWISKO STUDENTA

STUDENT FORMTEXT DOB PARENT
(IMIĘ I NAZWISKO STUDENTA) (ROK KIERUNEK SYSTEM
(IMIĘ I NAZWISKO STUDENTA) (ROK SPECJALNOŚĆ SYSTEM

POTOMAC STATE COLLEGE

STUDENT WITHDRAWAL INFORMATION

Name: ___________________________________________________ Year: _______________

WVU ID: _________________________________________________ Fall ____ Spring ____

Permanent Address: ________________________________________ Summer ____

________________________________________

International Student? Yes ___ No___

Visa Type: ______________________

________________________________________

Permanent Telephone: ______________________________________

REASON FOR WITHDRAWAL OTHER CONSIDERATIONS

(Please check only one reason): Currently receiving financial aid?

____Academic Difficulty (01) Yes ____ No ____

____Insufficient Financial Resources (02) Have you received student loans while

____Medical Problems (03) enrolled at PSC?

____Personal (04) Yes ____ No ____

____Lack of Interest (05) Do you live in PSC Housing?

____Dissatisfied with Course/Instructor (06) Yes ____ No ____

____Dissatisfied with this College (07) Residence Hall: ____________________

____Desired Courses not Available (08) Move out date: ____________________

____Career Plans Uncertain (09) Do you plan to return to PSC? _________

____Employment/Job Conflict (10) If yes, what term? ____________________

____Transfer (Name of Institution) __________________________ (11)

____Administrative Withdrawal (12)

____Other: Please Specify _________________________________ (13)

____Military – A review with an Enrollment Services withdrawal

professional is advisable with regard to a military withdrawal. To

process a full refund, we will need a copy of the student’s activation

papers. (14)

SIGNATURE REQUIRED:

I understand the following: 1) Any financial obligation due to PSC such as tuition, housing charges, chemistry laboratory breakage, library book fines, parking fines, etc., SHOULD be paid prior to withdrawal. 2) If I am contracted with PSC housing, I am required to vacate and return my keys within 24 hours of withdrawal. 3) My Student ID Card will be deactivated within 24 hours of withdrawal.

Student Signature: ______________________________________________ Date: ____________________

12-2017

(PREZIME OČEVO IME I IME STUDENTA) TELEFON
(IME I PREZIME PODNOSITELJA ZAHTJEVA –UČENIKSTUDENT) (
(IME I PREZIME UČENIKACE – STUDENTAICE) (PUNA

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