Withdrawal Petition Form - Access Request

This access request form will be sent directly to your major College Advising Center upon completion.

You must use this access request form to ask your College Advising Center to begin the Withdrawal Petition Form on your behalf.

PLEASE NOTE: Submitting this access request form is only the first step in a two-step process.

When your College Advising Center receives your request, they will review your details carefully and initiate a Withdrawal Petition Form on your behalf via Adobe Sign. Once initiated, you will receive a blank copy of the Withdrawal Petition Form in your Cal Poly email inbox.

YOU MUST open the Adobe Sign form, complete all required fields, and sign the document. Once you have signed, your Withdrawal Petition Form will continue to the next recipient for additional review and processing.

Student Name *

Cal Poly Email *

EMPL ID *

Please choose the College that houses your Major *

Your Major *

Are you hoping to withdraw from a COURSE or from the TERM? *

Course Withdrawal

Course Name *

Course Number and Section (Ex: ENGL 134-01) *

Name of Instructor *

Cal Poly email of Instructor *

Add another class

yes

Second Course to Withdraw

Course Name *

Course Number and Section (Ex: ENGL 134-01) *

Name of Instructor *

Cal Poly email of Instructor *

Add another class

yes

Third Course to Withdraw

Course Name *

Course Number and Section (Ex: ENGL 134-01) *

Name of Instructor *

Cal Poly email of Instructor *

Term Withdrawal

Which term do you want to withdraw from? (Ex: Fall 2024, Winter 2025, etc.) *

Last date of attendance for this term (MM/DD) *

Please explain why you need access to this form *

Please provide as much detail as possible for your College Advising Center. If your College Advising Center deems it appropriate to initiate a Withdrawal Petition Form on your behalf, you will have the opportunity to explain the circumstances surrounding your withdrawal (to your comfort level) on the form itself.

Leave this field blank

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