Temporary Withdraw PDF

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This is Temporary Withdraw...

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REQUEST TO TEMPORARILY WITHDRAW FROM DEGREE PROGRAM Instructions: By signing and submitting this form, you are requesting that the Registrar Office of Broward College – Vietnam Center temporarily withdraw you from your requested degree program on the date indicated and you will re-register within 12 months. You are acknowledging that the stop-out period is included in the time period for completion of your degree. Student Details: Full Name: ...................................................................................................................................................................... BC I.D: ................................................................................ BCVN I.D: ........................................................................... Email Adress: ..................................................................... Program: ............................................................................ Phone Number: ................................................................. Family Contact: .................................................................. Last date of attendance: ................................................... Last term of attendance: ................................................... I apply for permission to temporary withdrawal and agree to resume the program in the Fall / Winter / Summer 20____ session (maximum 12 months). Primary Reason for Withdrawal (Please select one option)

 Financial

 Employment difficulties

 Medical

 To seek employment

 Personal/Family

 Program unsuitable

 Transfer to another school

 Other reason – please give details:

Brief explanation:

Student Signature: By signing below, I confirm that I have discussed withdrawing with my Advisor, I understand the implications of withdrawing from my program. I certify that the information contained on this form is true and accurate.

Parent Signature:

Date:

Date:

Dean of the Program

Date: Registrar’s Office

Date:...