Masters
Online Student Withdrawal Form
Temporary or Permanent
Please
print a copy of this form, fill in your information, and fax or mail to the
address below:
Houston Baptist University Date: ___________________
Graduate Admissions Office
7502 Fondren Rd District: _________________
Houston, TX 77074-3298
Fax: 281.649.3011
Temporary
Withdrawal
( )
Please place a check to
Permanent Withdrawal (
) If
indicate
which quarter(s) you will not be attending and
permanently withdrawing, check above
which
quarter you will return
& complete all information below.
|
Quarter(s)
not attending: |
Quarter
to Re-enter: (Yr)________ |
||
|
Fall
( ) |
Spring
( ) |
Fall
( ) |
Spring
( ) |
|
Winter
( ) |
Summer
( ) |
Winter
( ) |
Summer
( ) |
(Please
print in ink or type)
Name:
________________________________________________ Social Security Number:
______-_____-__________
Last
First
Middle
Name:
________________________________________________ Last Quarter/Year Attended:
___________________
* Previously used name(s)
(for which grades were issued)
*Note:
Name as it appeared when previously enrolled. A name CHANGE form must be
obtained and completed from the HBU registrar’s Office before your name
change is reflected on your HBU record.
Present
Mailing Address
Home Phone (____)_______________
______________________________________________
______________________________________________
Business Phone (
) ____________
City
State
Zip Code
County
Permanent
Mailing Address (if different from above)
______________________________________________
______________________________________________
City
State
Zip Code
County
U.S.
Citizen (
)
International (
)
Permanent
Resident Alien
( )
Visa: Type __________________________
Number: __________________________
Country of Citizenship: ________________
Signature:
___________________________________________________________________
Date: _____________
FOR OFFICE USE ONLY
Program Director
Accepted:
_________________________________
Date: _________________________