Withdrawal from University Form

Online & Evening Program

Name*

First Name

Last Name

Student Number*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Reason for Withdrawal*

Financial Medical Personal Academic Other

Details:

When would you like your withdrawal from the university to be effective?*

*Immediately (withdraw me from all my classes) End of the semester (I expect to complete this semester and receive grades)

*Please review the General Refund Policy found in the academic catalog (catalog.limestone.edu)

*The Registrar’s Office will notify current instructors of your withdrawal and delete registrations for future classes.

Signature*

Use your mouse or finger to draw your signature above

Date/Time*