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STUDENT AND CLASS INFORMATION TYPE OR PRINT CLEARLY Name First Last Date Student ID Phone Semester Please indicate the reason for withdrawing q Personal Illness q Family Hardship q Financial Hardship q Academic Difficulty q Other please specify CRN 5 Digit if known COURSE SUBJECT e.g. ENG MAT HIS NUMBER SECTION LAST DATE OF ATTENDANCE per the instructor INSTRUCTOR SIGNATURE Note Distance Learning Office will need to obtain the last date of attendance for hosted online courses. HOURS REMAINING...

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