Petition For Retroactive Withdrawal Page 2

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STEP 2: Term and course information
In which term and year are you requesting a retroactive withdrawal? Term ________________ Year _______________
From which course(s) are you requesting a retroactive withdrawal?
Course subject
Course name
Credits
and number
STEP 3: Documentation of extenuating circumstances
Describe the serious and compelling reasons (usually due to serious accident or illness) justifying the withdrawal and the
extenuating circumstances justifying its retroactive nature. Attach appropriate documentation to support your statement.
Page 2 of 3
Revised 2/22/2016

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