UNDERGRADUATE EDUCATION/WITHDRAWAL AND READMISSION, LC-30
UNIVERSITY AT ALBANY, ALBANY, NEW YORK 12222
PHONE: (518) 442-5821
FAX: (518) 442-4959
WITHDRAWAL FORM FOR MATRICULATED UNDERGRADUATE STUDENTS ONLY
Matriculated undergraduate students who are withdrawing from all courses for a semester, or who wish to
discontinue attendance at the University, must complete this form. Failure to do so may result in loss of financial
adjustments, academic consequences, and/or the opportunity to reenter at a later date. You will receive written
confirmation once the processing of your withdrawal has been completed.
NOTE: IF YOU ARE CURRENTLY REGISTERED, THE OFFICIAL DATE
OF WITHDRAWAL IS THE DATE THIS FORM IS RECEIVED.
PLEASE PRINT
Name _________________________________________________________________________________
Last
First
MI
Student ID# _____________________________________________
Date of Birth ____/____/________
MM /
DD
/ YYYY
Permanent Address _____________________________________________________________________
Street
City
State
Zip
Mailing Address________________________________________________________________________
Street
Phone (Home) (
City
State
) ________________________ (Cell) (
Zip
) ______________________________
Please indicate the term which you would like to withdraw from1: __________________________________
Are you completing the semester? ( ) Yes ( ) No
Date of Last Class Attendance: ______/______/_____
MM
/
DD
/ YYYY
1
Please be aware if you are preregistered for classes for a future term, your registration will be cancelled.
Do you live on campus?
( ) Yes2 ( ) No
Do you receive financial aid?
( ) Yes2 ( ) No
2
If yes, you must contact the department regarding your housing contract and/or aid.
Are you returning?
Yes_____
No_____
If yes, when _________/_________
semester
/
year
Please be aware that your re-enrollment can only be guaranteed if you return the re-enrollment form to this office
NO LATER than July 15th if you intend to return for the Fall Semester or January 5th for the Spring Semester.
If you are leaving the University for Medical reasons, Psychological reasons, or being called to Active Military
Duty please see the reverse side of this form.

If other than the above reasons, check which one of the following is the Primary Reason for your
withdrawal:
(
(
(
(
(
(
(
(
) Need a break from academics
) Programs wanted were not available
) Dissatisfied with performance
) Dissatisfied with instructors
) Disliked demands of study
) Not academically challenged
) Could not identify with students
) Work and school conflicts
(
(
(
(
(
(
(
) Family responsibilities
) Disliked residence hall life
) College experience not as expected
) Unsure of academic goals
) Changed academic goals
) Health problems undocumented
) Other
Please continue on to side 2...

( ) Medical Reasons: Please note the withdrawal form will be processed immediately upon receipt,
pending a recommendation from the University Health Center. Medical/psychological clearance is
always required as part of the readmission process in the case of a withdrawal of this nature. If your
reason for leaving the University is due to medical or psychological difficulties for which you are
under treatment, you must provide supporting documentation from your licensed healthcare
practitioner or treatment facility. You will be given information, in writing, regarding the
documentation you are responsible for providing. This documentation must be sent or faxed to the
University Health Center within 15 calendar days of the date you submit this form.
Contact information for the University Health Center:
Phone: (518) 956-8421 Fax: (518) 956-8422

( ) Psychological Difficulties: Please note the withdrawal form will be processed immediately upon
receipt, pending a recommendation from the University Counseling Center. Medical/psychological
clearance is always required as part of the readmission process in the case of a withdrawal of this
nature. If your reason for leaving the University is due to medical or psychological difficulties for
which you are under treatment, you must provide supporting documentation from your licensed
healthcare practitioner or treatment facility. You will be given information, in writing, regarding the
documentation you are responsible for providing. This documentation must be sent or faxed to the
University Counseling Center within 15 calendar days of the date you submit this form.
Contact information for the University Counseling Center:
Phone: (518) 442-5800 Fax: (518) 442-3096

( ) Active Military Duty: If your reason for leaving the University is due to full-time active military
duty in the service of the United States of America, you must provide a copy of your active duty
orders to this office within 15 calendar days of the date you submit this form.
If a Disciplinary Suspension or Disciplinary Dismissal is pending: You should be certain to
discuss either of these circumstances with a representative from the Office of the Vice Provost for
Undergraduate Education and with the Office of Conflict Resolution. A student shall not be exempt
from disciplinary proceedings for behavioral infractions which occurred prior to leaving. A
withdrawal does not preclude a disciplinary referral.
Do you intend to transfer? ( ) Yes ( ) No
If so, to which college/university?
I have decided to leave the University. If I am leaving during the term (up to and including the last day
of classes), I am aware that I will be dropped from all of my current courses. However, if I am leaving
after the conclusion of the term, I will receive grades. I understand that my grades and financial
liability will be based on the date I submit this form and not an earlier date, regardless of my date
of last class attendance.
Making false statements and/or filing forged documents and/or submitting false material to a
University representative violates the standards of academic integrity. Such violations are subject
to appropriate disciplinary action.
**SIGNATURE_____________________________________________ DATE____/____/________
OFFICE USE ONLY:
Date Form Received
Date St. Health/Counseling Notified
Date Conferred with Judicial Affairs
Reg. Action: None__________________
Withdrawal
______________________________ By________________________________________
_________ By_____ Date St. Accounts Notified of Medical/Military _________ By_____
______________________________ By__________________
Future Registration Cancelled___________________
Departure
______/______/_____ Official Withdrawal Date
Month /
Day
/ Year
Updated: 12/2011