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Withdrawal, Leave of Absence, and Graduation Notification Form

Student's Name

*

*

Student's Email

*

Staff Name

*

*

Updated Status

Notes

Effective Date of Change

Date Change Determined (DoD)

Last Date of Activity (LDA)

Screenshot of LDA for the Student in Pivot (Course 1)

Screenshot of LDA for the Student in Pivot (Course 2)

Screenshot of LDA for the Student in Pivot (Course 3)

Notes