Withdrawal and Refund Application Form

(HIGHER EDUCATION ONLY)

WITHDRAWAL AND REFUND APPLICATION FORM

1. APPLICATION TO WITHDRAW

2. APPLICATION FOR WITHDRAWAL AND REFUND

3. APPLICATION FOR REFUND UNDER COMPASSIONATE AND COMPELLING CIRUCUMSTANCES

Please refer to the Higher Education Refund Agreement for conditions under which a refund will be granted

Student Identification Number / Postal Address / Residency Status
Domestic International
(Please select one)
Family Name:
Given Name: / Contact details
Mob:
Phone:
Email:
Application Type
I wish to (Please select one) / International students please note that your Visa may be affected as a result of a withdrawal. Contact your International Student Advisor or DIAC for further information before submitting this form.
Withdraw from unit (s)
Apply for withdrawal and refund
Apply for withdrawal and refund under compassionate and compelling circumstances
Course and Unit Information
The course and units relevant to this application include
Course Code:______/ Course Name:______
Year / Study Period / Unit Code / Unit Title
Reasons for your application
COMPULSORY: Please provide detailed reasons for your application. If you require more space, please attach a separate sheet. Please include independent, original or certified documentary evidence in your application (e.g medical certificate, letter from counsellor, letter from employer).

Account Details

Bank Details for Refund
(local and International Banks) / OR / Details for Credit Card Refund
(Fees paid via credit card will be refunded to that account)
Bank Name: / Credit Card Holder
Bank Branch / Credit Card Type
Bank Address
(No P.O Box): / Credit Card Number / _ _ _ _/_ _ _ _ /_ _ _ _ /_ _ _ _
BSB Number / SWIFT Code and /or IBAN Number: / Expiry Date
Account Number: / Signature of card Holder
Account Holder Name:

Are there any attachments to this form? ______How many pages are attached?______

Declaration

I have read and understood the Higher Education Refund Agreement

I hereby certify that the information provided in this application is correct.

I authorise North Metropolitan TAFE to gather and obtain any necessary information pertaining to this application based on the supporting documentation provided.

Print Name ______

Signed ______Date______