REQUEST TO WITHDRAW
See Article 6.9 of the Graduate School Policy Handbook for Guidelines.
Submit form to Graduate School – N204 / / THE GRADUATE SCHOOL OF BIOMEDICAL SCIENCES
BAYLOR COLLEGE OF
MEDICINE

Student Name: ______BCM ID #: ______

Graduate Program: ______(Are you also in the MD/PhD Program?  Yes  No)

EFFECTIVE DATE OF WITHDRAWAL: ______

REASON: ______

______

______

______

______

Student’s Signature: ______Date Signed: ______

Forwarding Address: ______Telephone:

______(____) ______

______

______

REQUIRED APPROVALS

OF WITHDRAWAL ON THE DATE STATED ABOVE

MAJOR ADVISOR: ______

SIGNATURE DATE

MAJOR ADVISOR: ______

SIGNATURE DATE

GRADUATE PROGRAM DIRECTOR: ______

SIGNATURE DATE

DEAN OF THE GRADUATE SCHOOL: ______

(signs after COMPLETION OF CLEARANCE PROCESS) SIGNATURE DATE

(OVER)

WITHDRAWAL FORM — Page 2

WITHDRAWAL CLEARANCE PROCESS

REQUIRED BY BAYLOR COLLEGE OF MEDICINE

STUDENT WITHDRAWING: ______BCM ID #: ______

WITHDRAWAL DATE: ______

s FINAL TRANSCRIPT HAS BEEN REVIEWED AND APPROVED, WITH EXCEPTIONS NOTED ON TRANSCRIPT:

______

Student’s Signature Date

s WITHDRAWAL FORM HAS BEEN REVIEWED AND APPROVED BY THE GRADUATE SCHOOL AND THE STUDENT MAY PROCEED WITH THE CLEARANCE PROCESS.

______

Graduate School Date

SIGNATURES BELOW INDICATE DESIGNATED RESPONSIBILITIES HAVE BEEN MET

SIGNATURES MUST BE OBTAINED IN THIS ORDER / Signature / Date
Benefits (Student Health Insurance) Insurance coverage terminates the last day of the month in which a student graduates or withdraws. Although BCM does not endorse any particular health insurance company, the following are possible resources for purchasing an individual policy: Ehealth Insurance, Government Marketplace or Wortham Insurance
Student’s signature acknowledges receipt of this information X______ / No signature required from Benefits.
International Services Office – McGovern Campus, OW100
For Foreign Students Only.
Student Account Services - Signature by appointment only at Including all fees, other charges on student account
Collection of $______is required to clear this account.
Student Account Services - Signature by appointment only at Student Loans
Collection of $______is required to clear this account.
Schol. & Student Financial Planning - N104
If you have received Financial Aid, you may experience some waiting when you clear with this office. This process takes time. Please be patient.
TMC Library
Account is closed if student is leaving Baylor. If remaining at Baylor as a Postdoc, account is changed accordingly.
Security – BCM 108H
ID badge turned in here.

COMPLETED FORM MUST BE RETURNED TO THE GRADUATE SCHOOL OFFICE BY THE STUDENT

Revised 5.24.2017