UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE



FORM TITLE:  MONITORED WITHDRAWAL REQUEST

NUMBER:      FORM 0037

PROCEDURE:   09-01-07





ENTER THE FOLLOWING INFORMATION WHERE INDICATED:



1.   Social Security Number of Student.



2.   Check one to indicate student level: Undergraduate or Graduate

     (Includes First Professional) level.



3.   Year the Term Begins.



4.   Name of Student (Last, First, MI).



5.   Name of Academic Center offering the course.



6.   CRN (5 digit Course Reference Number).  This number uniquely

     identifies a section of a course.



7.   CRN of Linked Lab (If Applicable).  This number uniquely

     identifies the zero credit Lab section associated with the

     lecture.



8.   CRN of Linked Recitation (If Applicable).  This number uniquely

     identifies the zero credit Recitation section associated with the

     lecture.



9.   Subject Area Abbreviation (Up to 6 characters).



10.  Course Number (4 digits).



11.  Course Title.



12.  Signature of Student and Date.



13.  Signature of Instructor of the course and Date.



14.  Signature of Academic Dean of Academic Center offering the

     course.