Jay College Withdrawal Form
Today's Date *
MM
/
DD
/
YYYY
First Name *
Last Name *
Middle Name *
Social Security *
Phone Number *
Email Address *
Program of study *
Required
Reasons for withdrawal *
Required
DO YOU WISH TO BE WITHDRAWN FROM YOUR CURRENT COURSEWORK? *
Required
Term of withdrawal (Year) *
Courses Attended (select all that apply) *
Required
I AFFIRM THAT THE INFORMATION ON THIS WITHDRAWAL FORM IS ACCURATE AND THAT I HAVE INFORMED MY ADVISOR THAT I AM WITHDRAWING FROM MY PROGRAM AND THE SCHOOL OF EDUCATION. *
Required
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