Araraquara, ____ de _____________________ de __________.

Ao() Coordenador(a) do Programa de Ps-Graduao em _____________________________

Eu,______________________________________________, CPF:___________________-____,

aluno(a) regularmente matriculado(a) no Programa de Ps-Graduao em

__________________________________, curso de Mestrado Doutorado, solicito

cancelamento de matrcula na(s) seguinte(s) disciplina(s):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

pelos motivos abaixo expostos:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Nestes termos, peo deferimento.

_____________________________
Assinatura aluno(a)

De acordo.

Orientador: Prof(a) Dr(a): _____________________________________________________

_________________________
Assinatura orientador(a)