Course Withdrawal & Release Form

COURSE WITHDRAWAL & RELEASE FORM
Part A. Personal Details:
Student ID:*
Given Name:*
Family Name:
Date of Birth:*

DayMonthYear
MaleFemale
Mobile Number:*
Format: (000) 000-0000.
Email Validator:*
Repeat Email Address:*
Address:*
Part B. Course Details:
Course Enrolled:*
Group No:
Course Start Date:*

DayMonthYear
Proposed Finish Date:*

DayMonthYear
Part C. Reason Details:
I wish to withdraw from the course I am enrolled in with HIC. I wish to withdraw for the following reason(s):*
Attached supporting documents:*

Cancelof
Part D. Student Declaration:
The information provided by me is true and correct. I have read and understood the information on this form. I have provided the following required information:
- Detailed letter including reason(s) for requesting a course withdrawal
- Provided documents as mentioned in the important note section of this form
- Refund Application Form (If applicable)
Student Signature:*

Clear
Date:*

DayMonthYear
Should be Empty:

Part A. Personal Details: