Withdrawal Form

***BEFORE WITHDRAWING CONSULT WITH YOUR ADVISER***

Withdrawal Form

Student Name: ____________________________ 

PSU ID: ___________________________

Reason:

_____Medical  _____Military _____Other

Date Last Class Attended_____________

Effective: 

_____Fall  _____Spring  _____Summer  _____Summer ONLY      Year:_________

I elect to withdraw from The Pennsylvania State University with the understanding of the following:

  • I am withdrawing from all my credit courses.
  • My course registration for all future semesters will be cancelled. I will need to be re-enrolled to return.
  • In the case of a summer-only withdrawal, fall registration will be maintained and re-enrollment is not necessary.
  • I understand that withdrawing might have a financial impact on my financial aid and health insurance benefits.
  • I understand that if I have borrowed federal or University loans during my career at Penn State, and I withdraw, even for just one fall or spring semester, that I will be required to complete the Loan Exit Interview on eLion (eLion.psu.edu) in order to fulfill University Policy and federal regulations. If I do not complete the Loan Exit Interview, registration and transcript holds may be placed on my academic records.

Student Signature: __________________________________________

Date: _____________________

Instructions:

  1. You may not withdraw after the last day of classes.
  2. *A copy of your military orders must accompany the withdrawal form.
  3. **Enter today's date as date last class attended, unless you can provide evidence that the date should be earlier.
  4. For the policy regarding tuition adjustments, go to: www.bursar.psu.edu/adjustments.cfm.
  5. Sign and mail or fax this form to:
    • For undergraduate students at University Park - The Registrar's Office, 112 Shields Building, fax 814-863-1929
    • For graduate students at University Park - Graduate Enrollment Services, 114 Kern Building, fax 814-863-4627
    • For students at other campuses - The campus Registrar's Office or office of the campus Director of Academic Affairs

FOR OFFICE USE ONLY
NCRR _____ Blended _____
Course Name(s)
Start Date
End Date

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