AICSE of Assessment Submission Extension Form

Please use Block/Capital Letters. When questions are not applicable to your circumstances, please specify with “N/A”.

Please tick all relevant boxes where they are applicable.

For the deferral of assessment submission including practical observation, please submit this form to Student Support H.E.A.R.T. Service Team at info@aicse.edu.au NO LATER THAN THREE WORKING DAYS after due date unless compassionate and compelling circumstances (See the definition of compassionate and compelling circumstances at Assessment Policy and Procedures. You are required to attach supporting evidence (e.g., medical certificate) with your application.

Please note the following points before filling the form--

Please use Block/Capital Letters.
When questions are not applicable to your circumstances, please specify with “N/A”.
Please tick all relevant boxes where they are applicable.

Name*

PrefixFirst NameLast Name

Gender*

MaleFemaleOther

Student ID*

Current Course/s Name:*

Campus*

Liverpool

Phone Number*

Email*

example@example.com

(Provide CORRECT unit code and name in BLOCK LETTERS)*

	Unit Code	Unit Name	Assessment name	Assessment due date	Trainer’s name
1
2
3
4
5
6
7
8
9
10

Description of Circumstances

Please tick all relevant boxes where they are applicable and clearly state the circumstances that have an impact on your studies. You must state the affected duration (in days, weeks or months). *

Serious illness (Please attach medical certificate)Death or serious illness of immediate family member (Please attach a letter from a counsellor, doctor or health practitioner indicating the condition. Please provide the proof of the relationship between family member and the student)Crisis/trauma (Supporting evidence may include a medical certificate or other documents from counsellor, doctor, or police depending on the nature of the issue. The evidence must demonstrate the severity and/or gravity of the circumstance which can impact the student’s studies).Mandatory commitments (The student has unavoidable commitments such as jury duty, court appearance, military reserve activities and, emergency service commitments. Please attach documentation showing compulsory appearance dates).Other

You must attach SUPPORTING DOCUMENT (e.g., medical certificate, letter from a health counsellor).*

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Have your contact details changed since you last advised us of them? Type a question*

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Post Code

• I declare that to the best of my knowledge, the information supplied by me is true, correct and complete in every respect.
• I am aware that if I extend the duration of my assessment submission I may need to extend my eCoE, and in the event that my visa expires prior to the completion of the course, I will be required to apply for a new student visa to complete the study.

Full Name

Your Signature

Date