Graduate Student Separation Form printable pdf download

Graduate Student Separation Form

Name:____________________________________________ Student ID number__________________________

Last

First

Reason for leaving CLU: ____Graduation

Expected Graduation date:_____/_____/_______

(completed studies)

dd year

Are you planning to attend the graduation/commencement ceremony in May? ____Yes ____No

____Early separation from CLU

Reason for Separation_________________

Will you complete the present term? ____Yes ____No

Forwarding Address:___________________________________________________________

____________________________________________________________

New email Address

:_____________________________ Cell phone:______________________

(please print clearly)

Signature:____________________________________________ Date:___________________________

Students separating from the graduate program must obtain clearance from the offices below before the request becomes

effective. Please return the completed form to the International Programs Office.

Office Departmental Signatures

Date

Academic Department

__________________________________________ ____________

Academic Department Advisor/Representative

Library/ISS (Circulation Desk)

_________________________________________ ____________

All books returned and email deactivated

Health Services (Kramer Court)

_________________________________________ _____________

Close your file

Student Accounts (Business Office) _________________________________________ _____________

Account review for clearance of any balances due

Registrar (Hanson Admin Bldg) _________________________________________ _____________

Academic course review

University Housing (Mogen Hall) _________________________________________ _____________

Unit clean/undamaged – See Chris Paul (if applies)

International Programs (SUB) _________________________________________ _____________

Final step – Turn in completed form – Dr. Juanita Hall

Graduate Student Separation Form