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Request to Withdraw from Program

Your Name: *
(or other name(s) you may have used in the past.)
Date of Birth: *
Your Mailing Address: *
(for the next six months)
Street: City: State: Zip:
Your Email Address: *

I hereby request to withdraw from the Vermont Law School Distance Learning Program. *     LLM    Masters
(Please indicate which program you are withdrawing from.)
On what date did you last log into the LMS system? *
Main Reason for Leaving Vermont Law School: *
(Please select one option)
Cost of attending VLS
Health problems
Availability of financial aid
Change in family situation
Program wasn't what I expected
Other (Please specify in Comments section below.)

Thank you for taking the time to fill out this questionnaire.
Please indicate if you would be willing to discuss your answers via telephone or email. *     Yes    No
A good time to reach me:
My telephone number:
Information Collection Disclosure:

The information you enter here is retained by VLS for internal use, and may be submitted to third-party tools or entities for specific, related purposes such as payment processing or reporting. All data is collected and retained via secure protocols. Click here to read relevant policy information.
European Union residents, click here to request removal of your data from our systems.

Please check this box to indicate that you understand the data retention policy information.

NB: Submitting this form acts as your signature on this document.