For academic department use only
This form is used by the instructor to request an administrative withdrawal of a student due to class disruption.
Do not return this form to the Office of the Registrar. The original copy must be submitted to the Associate Provost for Faculty and Academic Affairs. A copy of the completed form should be kept in the department office.
Download Administrative Withdrawal Due to Class Disruption form (Fillable PDF updated 9/14/21)
Download Administrative Withdrawal Due to Class Disruption form (Word version updated 9/14/21)
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