Withdrawal Form We're at your service. PC Processed by: University Housing and Tniils Date 1S BB Ema Meal Plan ws Persona PANTHER CENTRAL interyiew Record Witherawal From: Catt spring Cisunmer Academic Term for Cancel ‘Student Information (pleese rit) Name Birth Date PeopleSoft # Housing Assignment/Bullding Room # Bedspace # Contact phone # Cancel: Housing contract teat Pian Reason for Withdrawal: 1. Verifies Resignation from School 1. tovoluntary Service in U.S. mitary 11. Verified Medial Problem Necsstating 1D Geauation Resignation from School DD Academic vismissat, Tote (deta Beto Explanation: If returning for spring and require on campus housing, include three preferences: 1 2, 3 Student's Signature Date 1 canceling fr fal, need fr spring housing: Cves Ono Guscantee: Retain Crortett Deposit: Refund CO Forfeit Coté for spring Approved By: Date University of Pittsburgh wm Housing Services m Dining Services m Panther Card a Litchfield Towers Lobby, 3990 Fifth Avenue, Pittsburgh, PA 15213, 412-648-1100, www.pcpittedu, E-mail: po@bcpitt.edu