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REQUEST FOR COURSE WITHDRAWAL

Student ID Number:

SECTION A: PERSONAL DETAILS

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Name *

First

Middle

Last

Address

Date of Birth

Telephone:

Fax

Email

Program

Major 1

Major 2

Minor

Are you sponsored?

Yes
No

If yes, the name of sponsor

SECTION B: REQUEST DETAILS

I wish to withdraw from the following course(s):

Reasons for withdrawal

Are you a sponsored or private student?

Private
Sponsored (attach a written and signed approval from your sponsor)

I am aware that I am liable for any outstanding fees associated with my withdrawal from the courses named above and take full responsibility for ensuring that all outstanding fees are paid in full. I am also aware that an administration fee may apply for my withdrawal.

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Signature

Clear Signature

Date