USVI Public Records

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Albert A. Sheen Campus RR1, Box 10,000, Kingshill, VI 00850-9781 St. Thomas Campus #2 John Brewers Bay, St. Thomas, VI 00802-9990 Request for Administrative Withdrawal Students who could not complete coursework due to unusual circumstances may request an administrative Withdrawal from course(s) after the University’s official withdrawal date. All parts must be completed before this request will be reviewed. o Complete this form o Attach a typed letter explaining how circumstances impacted the student ability to complete coursework, written by the student; and o Provide supporting documentation. Relevant documentation may include:  A doctor’s statement written on physician’s letterhead (not a prescription pad).  Employer’s statement on letterhead with specific dates of changes in employment;  Instructor’s written statement with specific dates, reasons, and additional information to document extenuating circumstances and accommodations made;  Police reports and/or legal documents listing specific dates of incidents; or  Any other documentation that would indicate proof of mitigating circumstances. SECTION A: Student Information (Please Print legibly). Date: _______________ Student ID#: _______________________________Last date of Attendance: Name: ____________________________________________________ Last First Middle Email address: _____________________________________________________ Telephone contact: _____________________________ SECTION B: Request (Please Print legibly). Semester: Fall Spring Summer Year__________ CRN# Subject Code CRSE # Title of Course Credits I am requesting to withdraw for the following reason(s): (Please State Reason(s): __________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Student Signature: __________________________________________________ Date:_________________________________ Approval(s): School/College Dean’s Signature____________________________________________________ Date: ____________________________ Provost Signature ________________________________________________________________ Date: ____________________________ 2/15/2016 SIGN SIGN SIGN