Request for Authorized

Withdrawal Tuition Credit

 

____________________________________________ ___________________________________
Student Name IRN

Reason for Tuition Credit Request (This section must be completed):

⃞ Family Medical Leave ⃞ Personal Leave ⃞ Jury Duty ⃞ Course Cancellation/University Related
⃞ Military ⃞ Other (including business related leaves):_______________________________________

Students who withdraw from a course due to extenuating circumstances, are in good academic standing,
receive a “W” grade and are in compliance with their chosen payment option may request an Authorized
Withdrawal Tuition Credit. Students who receive a “WF” grade are not eligible for the tuition credit. A
credit will not be granted for any course to which an Authorized Withdrawal Tuition Credit has
previously been applied. The request must be made in writing, be approved by designated campus
supervisor, and be submitted within 59 days from the end date of the course for which the “W” was
received. If the request is approved, the credit may be applied to any course taken within 60 days from
the end date of the course that was assessed the “W” grade. If the amount of the credit is greater than the
tuition rate of the future course, the remaining credit can be applied to another course only if the course
also starts within 60 days from the end date of the course for which the “W” grade was given. Any credit
is non-transferable to other students but may be used at any UOP campus. No cash refunds will be
given.
 
By signing this form, I am requesting a withdrawal tuition credit and I understand the policies listed above.

____________________________________________ ___________________________________
Student Name Date

THIS SECTION IS FOR CAMPUS USE ONLY ⃞ Deny ⃞ Approve

____________________________________________ ___________________________________
Last Day of Class Attendance Scheduled Re-Entry Date

_____________________________________________________ ___________________________________
Campus Representative (Printed Name and Signature) Date

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