Sponsorship Separation Form

Student Organization Information

Name of Student Organization

Name of Sponsoring Department/Unit

Statement of Intention
We hereby certify that we (check all that apply)

Wish to separate from the current sponsoring department/agency

Wish to remain active as a registered student organization

Wish to no longer be active as a registered student organization

Reason your organization has decided to separate:

I am submitting this form on behalf of

The sponsoring department

The advisor

The student organization