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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.

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

Graduate students, please contact your graduate department office for information about withdrawing from Brockport.

Undergraduate Students:  The last day to withdraw from all courses for the Spring 2012 semester was Friday, April 27.  Late withdrawals from All courses at any time AFTER April 27 require the approval of the Vice Provost's Office to extend the withdrawal deadline.  Contact Dr. Eileen Daniel, Associate Vice Provost at 585.395.5505 for a leave after April 27

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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:  The deadline to withdraw from all Spring courses has passed.  Late withdrawals from All courses at any time AFTER April 27 require the approval of the Vice Provost's Office to extend the withdrawal deadline. Contact Associate Vice Provost at 585.395.5505 for a leave after April.
	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 5/9/12

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