Withdrawal Form

Please provide the following information:

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Your Student Type:(Required):

This field is required.

Meeting Request:(Required):

This field is required.

Time of incident:

Specific location:

Student Information (complete all fields)

Involved party 1

Enter your full name

Your M-number (ex: M12345678)

Date of Birth (YYYY-MM-DD)

Phone number

Other email address (optional)

Questions

Select your primary reason for withdrawing.(Required) This field is required.

Select any secondary reasons for withdrawing.(Required)

Academic Financial (tuition cost) Financial (living expenses) Employment Transfer Medical (physical health) Medical (mental health) No secondary reason

You must make at least one selection.

What semester are you wanting to withdrawal from?(Required) This field is required.

Briefly explain your reason for withdrawing.(Required) This field is required.

Indicate if you are planning to return to Michigan Tech.(Required)

Yes - Summer 2024 Yes - Fall 2024 Yes - Spring 2025 Yes - Summer 2025 Yes - Fall 2025 Yes - another term not listed above No Unsure

This field is required.

Please provide a forwarding mailing address, phone number, and email address where you can be contacted after you leave Michigan Tech.(Required) This field is required.

I understand that the date of my withdrawal will impact the refund I may receive for this semester. During fall and spring, if I withdraw after week seven, I will not receive a refund for the semester. Summer term refunds are dependent on the date of the withdrawal and track in which you are registered.(Required)

Yes

You must make at least one selection.

I understand that if I live in campus housing, I must check out with my RA or Residence Education and Housing Services (REHS) in 153 Wadsworth Hall. For questions, contact REHS at 906-487-2682.(Required)

Yes

You must make at least one selection.

I understand that if I am an international student, I am required to consult with IPS prior to leaving campus to ensure I understand the visa consequences of my withdrawal. I understand that I will also need to provide my departure information to IPS before leaving. For questions, please contact IPS at 906-487-2160.(Required)

Yes

You must make at least one selection.

I understand that my financial aid may be adjusted based on my last date of attendance which may result in a balance due to Michigan Tech. For questions, please contact Financial Aid at 906-487-2622.(Required)

Yes

You must make at least one selection.

I understand if there is a balance due on my account, it must be paid prior to re-enrollment or my account may be sent to collections. For questions, please contact Financial Aid at 906-487-2622.(Required)

Yes

You must make at least one selection.

I understand that I will lose access to my Google Drive and Photos 120 days after not being actively enrolled. If I need assistance I will contact IT at it-help@mtu.edu.(Required)

Yes

You must make at least one selection.

Supporting Documentation

If you are withdrawing for medical reasons, please upload supporting information from your medical provider. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

Email me a copy of this report