Contact Information

First Name *

Last Name *

Forwarding or Permanent Address (street, city, state, zip, etc.) *

Social Security Number *

Student ID Number *

Your Birthday Date - (month, day, year) *

Email Address *

Phone Number *

Withdrawal Information

Semester from which you plan to withdraw (example: Spring 2018) *

Your Enrollment Location * Alva Enid Woodward Online Distance Other

If Other, please explain

Your Classification * Freshman Sophomore Junior Senior Graduate

What is your major? *

Have you attended classes? * Yes No

Semester started at Northwestern? (Example: Fall 2015) *

Have you completed an 8-week or 4-week class? * Yes No

Have you signed a dorm contract for this semester? * Yes No

Have you applied for financial aid (grants/loans/work)? * Yes No

Reasons for withdrawal from Northwestern? *

Is there anything Northwestern can do to assist you in maintaining your enrollment? * Yes No

Please explain *

Statement of Understanding * Yes, I understand No, I do not understand, and will contact you for an appointment to discuss this withdrawal

Student's Electronic Signature * Yes No

Any additional comments you'd like us to know: