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Notice of Intent to Withdraw on
Leave of Absence/Inactive Status

This form is for matriculated undergraduate students only, who can contact Academic Advisement if they have any questions.

Graduate and non-matriculated students, please contact Office of Registration and Records for information about withdrawing from Brockport.

Please acquaint yourself with the withdrawal policies, financial aid, financial obligations, and academic procedures of The College at Brockport before proceeding further.

Please enter all required information below.
(Required fields are marked with red )


I certify I have read and understand the withdrawal policies, financial aid, financial obligations, and academic procedures of The College at Brockport
Name: required
Student ID: required
Email: required
(we will send you a confirmation email on the next business day)
I have moved. Update my permanent address to:
(only complete this if you have a new permanent address)
Address 1:
Address 2:
City:
State:
Zip code:
Phone:
Please place me on the following status:
Leave of Absence (I understand that if I earn no credits for three consecurive semesters and am not enrolled for the subsequent fourth semester, any leave will expire and I will be considered on inactive status.)
Inactive/Separated Status
   
Make this effective:
Now
At the end of the current semester
   
I am now registered for
 
Fall
Winter
Spring
Summer
Please do not drop the course(s) that I pre-registered for:
(Leave of Absence Only)
Fall
Winter
Spring
Summer
I am a matriculated undergraduate. This is my first indication of intent to withdraw from the College, and today is my last day of class attendance.

Contact Information:

Matriculated Undergraduate Students:

Office of Academic Advisement
The College at Brockport
350 New Campus Drive
Brockport, NY 14420
phone: (585) 395-2711
fax: (585) 395-2708
advise@brockport.edu		 Graduate and Non-matriculated Students:

Office of Registration and Records
The College at Brockport
350 New Campus Drive
Brockport, NY 14420
phone: (585) 395 2531
fax: (585) 395-5392
registrar@brockport.edu