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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 Student Retention if they have any questions.

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

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

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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 consecutive 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 (your leave will be processed after grades post at the end of the 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 student. Completion of the online request form is my first indication of intent to withdraw from the College.  Please Note: For students requesting a Leave/Inactive status effective now, today is your last day of class attendance at the College at Brockport. For students requesting a Leave/Inactive status effective at the end of the current semester, your leave will be processed after grades post at the end of the semester.

 

Contact Information:

Matriculated Undergraduate Students: Office of Student Retention The College at Brockport 350 New Campus Drive Brockport, NY 14420 phone: (585) 395-5397 fax: (585) 395-5243 studentretention@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

Last Updated 1/3/12

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