Withdrawal Form printable pdf download

Office Use

Withdrawal Form

Important Notes:

It is recommended that students see their Program Coordinator or a Counsellor before withdrawing from the College.

This form is to be submitted to the Registrar’s Office along with the student’s Clinical ID card (if applicable).

It is the student’s responsibility to notify Sutherland Residence Village or Frost Residence of their withdrawal.

Parking passes must be returned to either the Information Kiosk at Sutherland Campus or the Cashier’s Office at Frost Campus.

If a student withdraws after the 10

day of scheduled classes, a refund will not be issued for the semester.

___________________

_____________________

___________

Last Name:

First Name:

Student Number:

Email Address: _____________________________ Preferred Phone Number: ______________________

Program: ________________________

Street Address: _________________________________________________________________________

Semester: ________________________

City:________________________________________ Province: __________ Postal: ______________

Campus: ________________________

Reason for Withdrawal:

Financial

Health

Obtained Employment

Personal

Transferring to another College

Progression

Other __________________________________________________________________________

Date of Withdrawal:

Effective Immediately

Effective End of Term

Student Signature: ____________________________________________________________

Date: _____________________________________

This Section to be completed only if an OSAP Student

Please include any income you have received from the first day of classes to the date of withdrawal.

A. Total gross income from Government benefits (excludes OSAP, GST, Child Tax or Universal Child Tax Benefit)

$________________

Type of Government Income: __________________________________________________

Total gross income from scholarships, bursaries and awards:

$________________

Total gross income from all other sources (including employment income):

$________________

The amount of OSAP you were eligible to receive will be recalculated based on the time that you were attending up until the actual withdrawal date. In

most situations, you will have received more OSAP funding than you were entitled to receive. Any overpayment on your OSAP account will be deducted

from future loans you receive (for this academic year) or you will be required to repay the overpaid amount. Any tuition fee refund that you are eligible to

receive will be directed to the National Student Loan Service Centre to pay down your loan and overpayment on your OSAP account file.

I hereby declare that the information provided on this form is true and accurate to the best of my knowledge.

Student Signature: _____________________________________________________________ Date: ________________________________________

Records Use Only:

Financial Aid use only:

Effective Date of Withdrawal:

___________________

Effective Date of Withdrawal: ___________________

Amount Paid:

$ _____________

Tuition Fee Adjustment

$ ____________________