Statement of withdrawal

First name:

Middle name:

Last name:

MtA e-mail:



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: