Withdrawal Request Form

First Name*

Middle Name

Last Name*

Penn ID*

E-mail Address*

Division/Program/Specialization*

Degree*

Term when withdrawal effective*

Spring
Summer
Fall

Year*

Date when withdrawal should become effective*

Last date of attendance in any class before withdrawal*

Reason for withdrawal*

Please provide an explanation*

Submission of this form does not automatically imply your withdrawal request is approved. If your withdrawal request is approved, you will receive a letter via email to the email address ON FILE in the Penn Directory.

Depending on when the withdrawal is requested, you may be subject to the partial refund schedule outlined on the Penn GSE Academic Calendar.