Withdrawal

Please complete this form if you plan to withdraw. Please note that the Office of the Registrar cannot approve the withdrawal until all listed departments (Financial Aid, Student Accounts, etc). You are required to meet with the Associate Dean of Student Affairs prior to completing this form.

Have you met with the Associate Dean?

Please DO NOT complete this form until you have met with the Associate Dean, Casey Himmelsbach.

Yes

Name of individual completing form

Student Number

Full Name*

Date of Birth*

Last Date of Attendance*

Withdrawal Type*

I am requesting to withdraw from all my courses and plan to return to Noorda-COM.

I am requesting to withdraw from all my courses and DO NOT plan to return to Noorda-COM in the future.

Expected Date of Return

If Other, Please Specify:

Withdrawal Reason Explanation*

Financial Aid Acknowledgment*

I have met with a Financial Aid Counselor and have been advised of both the current and future financial aid implications of my withdrawal.

Yes

Student Accounts Acknowledgment*

I have met with the Bursar, or his/her designee, and understand that withdrawing may result in me owing money to Noorda-COM. I also acknowledge that I am response for the continued payments to Noorda-COM.

Yes

Military-Connect Benefits*

Do you receive any military-connect benefits? {HPSP, VA, etc}

Yes

Military-Connected Benefits Acknowledgment*

I understand the impact that withdrawal may have on my military-connected benefits.

Yes

International Student Status*

Are you an international student?

Yes

International Student Acknowledgment*

I have met with and been advised of the impact of withdrawal on my student visa.

Yes

Library Acknowlegment*

I have return all resources and owe no fees to the library.

Yes

Please upload all associated documents

Financial Aid

Bursar

Library

Student Affairs

Military

File Upload

Drag and drop files here or

Affirmation*

I understand that by submitting this form to the Office of the Registrar, I will be withdrawn from all my courses. If the withdrawal occurs prior to the drop/add deadline, a notation will not appear on my transcript. If the withdrawal occurs after the drop/add deadline, a “W” will be reflected on my transcript. I understand that I am responsible for tuition and fees assessed according to the refund schedule in effect on the date that this form is submitted to the Office of the Registrar as dated below. I understand that my withdrawing from Noorda-COM will affect my eligibility to use campus facilities and to retain health insurance benefits. My current and future financial aid awards may be affected, and I may be liable for tuition owed as a result of the return of financial aid funds. Note: Non U.S. citizens who withdraw from Noorda-COM may jeopardize their immigration status and their ability to remain in the United States.

I acknowledge the affirmation statement.

Date Submitted*

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