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