PLEASE NOTE


Statement of withdrawal

First name:

Middle name:

Last name:

MtA e-mail:
  
  

Program:

                

Current year of study:

Student ID:

Intended withdrawal date (day/month/year):
 
  

Withdrawing from:


 Intended date of withdrawal (day/month/year) (required):
 
 
 
Intended date of withdrawal (day/month/year) (required):
 
  


 Intended date of withdrawal (day/month/year) (required):
 
  

Do you intend to return to Mount Allison to continue your studies in the future?
                                

If yes, please indicate your expected date of return:

 

Do you plan to take courses elsewhere that you intend to transfer to Mount Allison?

                

*If yes, please refer to academic regulation 10.5.1. The application for a letter of permission can be completed using our online letter of permission form.

 
Do you have a student loan?

                                

Current local address (residence room or off-campus):
 

Current local phone number:
 
 
Contact address:
  

Phone number:
 
  

Reason for withdrawal

                

Details, if "other" is selected:
 

 

Additional comments: