West 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:

Subject Identifier ie: ENG

Course Number:  

Section Number:  

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

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

Term and School Year
FA Year SP Year SU Year
Number of periods attended if Basic skills, High school or GED courses: 

Select One of the following codes for explanation of drop:

If you have entered 0's in the dates of attendance fields, be sure to select the
NA_Never Attended option from the drop down menu below.

Instuctor Cosmo ID:
Date: 00/00/0000

Instructor Signature:
Instructor Email:
A value is required.

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.