CS Late Withdraw Petition Form

Student Information

8-Digit Spire ID#

First Name

Last Name

Local Address

Local Phone

###-###-####

UMASS Email Address

Confirm UMASS Email

Primary Major

Secondary Major

Expected Graduation Date

(Month/Year)

Course History Information

Course Title

e.g., CMPSCI 105

Full Course Title

e.g., Introduction to Programming

Semester and Year

e.g., Fall 2016

5-Digit Class Schedule Number

This is the 5-digit class number for the specific class or section you are requesting to withdraw.

5-Digit Lab Number

If necessary, include the 5-digit class number for the specific lab you are requesting to withdraw.

Instructor's Name

For the course that you are requesting to withdraw, please provide the 3-digit catalog number, the full title, the semester & year, the schedule number, and the Instructor's name.

Justification

Reason For Request

Never attended (explain below)

Personal illness (explain below; requires verification from a physician)

Personal and/or family problems (explain below; requires verification, e.g. from a counselor, etc.)

Work schedule (explain below; requires verification of work schedule)

Other (explain below)

Briefly explain the reason for your request

I understand that this appeal will be reviewed by the Advising Committee and I will be notified of the decision by email. I understand that I must continue to attend the course(s) that I am requesting a late withdrawal(s) until I am notified that the late withdrawal(s) was approved. I understand that if verification is needed, that it is my responsibility to provide it to the committee.

Check here to indicate you have read and understand the above statements.

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