Notice Of Withdrawal Form
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2UNIVERSITY OF CALIFORNIA AT BERKELEY
ENGINEERING STUDENT SERVICES
COLLEGE OF ENGINEERING
230 BECHTEL ENGINEERING CENTER
NOTICE OF WITHDRAWAL
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WITHDRAWAL REQUESTED:
Today's Date ________________________________
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q
q
Retroactively from the
Fall
Spring
Semester 20___
NOTE: You have ten days from "Today's Date" to cancel your withdrawal. To do this you must meet with your Student Affairs Adviser.
SID NO: _____________________________________
Name: ___________________________________________________________________________________
last
first
middle
Local Address: ____________________________________________________________________________
no and street
city
state
zip
Email Address: _____________________________________
Permanent Address: _______________________________________________________________________
no and street
city
state
zip
Telephone No: Local (______)____________________
Permanent: (______)____________________
Birthdate: ____________________________________
First enrolled at Berkeley: ________________
Major: _______________________________________
Are you an F-1 or J-1 visa holder? _______
Last Class Attended: __________________________
Date Last Attended: ____________________
If you are an F-1 or J-1 visa holder, SISS signature_______________________________________________
print name
signature
date
q
q
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Reason for withdrawal:
Personal
Medical
Other
Explanation: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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q
S
Are you planning to resume studies at Berkeley? ______ if yes, when:
Fall
pring
Semester 20____
While not enrolled at UC Berkeley, courses taken at other colleges must be approved by the Associate Dean PRIOR to taking the course.
Signatures:
STUDENT: __________________________________________________
Date: __________________
Dean or Dean's Representative: __________________________________
Date: __________________
Updated 01/01/2016
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