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Student Name
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Afghanistan
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Antarctica
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Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
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Burkina Faso
Burundi
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Central African Republic
Chad
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Congo, Democratic Republic of the
Cook Islands
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Panama
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Samoa
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Tanzania, the United Republic of
Thailand
Timor-Leste
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Tonga
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US Minor Outlying Islands
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Vanuatu
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Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Telephone (Home) Phone
Cell/Work Phone
Program Title
*
Cosmetology
Barber Styling
Restricted Barbering
Full Specialty
Massage Therapy
Instructor Training
Nail Specialty
Facial Specialty
Last Date of Attendance
*
MM slash DD slash YYYY
Description
*
Change of Personal Information
Satisfactory Academic Progress
Change of Program
Leave of Absence
Probation
Suspension
Withdrawal
Re-enter
Cancel
Graduate
Placement at
Is your withdrawal related to the novel coronavirus disease (COVID-19)?
*
Yes
No
Please explain how COVID- 19 caused you to withdraw from MTI.
*
Allowable circumstances include, but are not limited to, illness of the student or family member, need to become a caregiver or first responder, loss of childcare, economic hardship, inability to access wi-fi due to closed facilities, class transition from on ground-based instruction to distance learning, closed campus housing or other campus facilities or an increase in work hours as a result of the COVID-19 emergency.
Effective Status Change Date
*
MM slash DD slash YYYY
Beginning Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Place of employment.
Comments
Request to withdraw due to the novel coronavirus disease (COVID-19)
*
I certify that I was affected by COVID-19 and the information that I provided is true and correct.
I understand that for students whose withdrawals are related to the novel coronavirus disease (COVID-19) Direct Loan funds received for the period will be canceled, the period will not count toward the student’s Subsidized Loan usage for purposes of the 150% Direct Subsidized Loan Limit, and Pell Grant funds received for the period will be excluded from the student’s Lifetime Eligibility Used (LEU).
Student Signature
*
Date
*
MM slash DD slash YYYY
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