Milwaukee Campus
Instructor Initiated Withdrawal Form

Note: Instructor Withdrawals DO NOT initiate a refund for the student

Student First  Name:

Student Last Name:    

Student Middle Initial:
Student ID Number:

Course Number:  

Section Number:  

First Date Attended (Month/Day/Year):
 If never attended, add 0 to the field  
A value is required.

Last Date Attended (Month/Day/Year)
 If never attended, add 0 to the field  

Select One of the following codes for explanation of drop:
If you have entered 0's in the first and last dates of attendance fields, be sure to select the NA_Never Attended option from the drop down menu below.
Term and School Year 
FA Year SP Year SU Year
Number of periods attended if Basic skills, High school or GED courses: 
Instuctor Cosmo ID:
Date: 00/00/0000

Instructor Signature:
Instructor Email:

MATC is an Affirmative Action/Equal Opportunity Institution and complies with all requirements of the Americans with Disabilities Act.

An email with a copy of the text on this form has been sent to the address you entered on the form. You may also want to print a copy of this form before you click submit.