UNDERGRADUATE EDUCATION/WITHDRAWAL AND READMISSION, LC-30
UNIVERSITY AT ALBANY, ALBANY, NEW YORK 12222
PHONE: (518) 442-3950
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.
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: ______/______/_____ ( ) check here if withdrawing prior to the start of classes
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
If you are leaving the University for Medical and or 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 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 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 Student Health Services:
Phone: (518) 956-8400 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. 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 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 Counseling and Psychological Services:
Phone: (518) 442-5800 Fax: (518) 442-3096
Withdrawal Information for Military Service
Students may request a withdrawal for military service at any time. If your reason for leaving the
university is due to active military duty in the United States Military, you must provide a copy of
your military orders along with the withdrawal form to the Office of the Vice Provost and Dean for
Undergraduate Education LC30. Please note that if the withdrawal is due to active duty during the
current term, students will receive a 100 percent tuition refund and a prorated refund of unused
room and board fees; an extension to complete the course with no tuition reimbursement may be
more appropriate when the call for active military duty comes near the end of the term. If you
receive Financial Aid and VA benefits please contact Randi McGlauflin at uaveteran@albany.edu
regarding your aid.
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 Community Standards. 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.
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____/____/________
Updated: 11/2/15
OFFICE USE ONLY:
Date form was received ____/_____/_____
Withdrawal
Departure _____ MWD
______/______/_____ Official Withdrawal Date