Cancellation Withdrawal Request Form - Durham College Residence
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1Durham College/UOIT Residence Cancellation / Withdrawal Request Form
Residence cancellations and/or withdrawals will not be granted until this form has been received. This form must be submitted to the Front Desk by students
at least 5 business days before the desired date of cancellation/withdrawal. Staff will contact the student to follow up with this request. Students are advised to
read and review the Termination and Cancellation section of the Student Residence Agreement (SRA) prior to submitting this request, which can be found
at: or Cancellations, withdrawals and refunds will be granted in accordance with these policy statements.
STEP 1: PERSONAL INFORMATION
Surname _______________________________________
First Name _______________________________________
Initial ______
Date ____
/
____
/
____
Anticipated Date of Withdrawal
____
/
____
/
____
Student Number
________________________
MM
DD
YY
MM
DD
YY
Mobile Number
_________________________
Room Number
__________
Email
__________________________________________
(country code) (area code)
STEP 2: REASON FOR WITHDRAWAL
❒
I am:
cancelling my application to live in residence (I have not yet moved in to residence), OR
❒
withdrawing from residence (I currently live in residence)
Please indicate your primary reason for cancelling/withdrawing. Select ONE choice only. Supporting documentation may be requested.
❒
❒
Academics – withdrawing from the College/University
Graduating / Program conclusion
❒
❒
Accepting admittance at another College/University
Medical
❒
❒
Co-Op / Work placement outside of the City
Moving off campus
❒
❒
College/University experience
Personal
❒
❒
Change in Career Plans
Residence experience
❒
❒
Financial – cost of residence, tuition, etc.
Other (Explain) _________________________________
By signing this form you are indicating that you wish to either: (a) cancel your application to live in residence, or (b) you wish to
terminate your residence contract and move out of residence. By signing this form you are also indicating that you have read and
understand the SRA and the Termination and Cancellation Policy.
❒
I agree that I
have read and understand the SRA and the Termination and Cancellation Policy
Date
____
/
____
/
____
MM
DD
YY
STEP 3: OVERALL SATISFACTION QUESTIONS
Please indicate your overall satisfaction with your residence experience:
❒
❒
❒
❒
❒
Very Satisfied
Satisfied
Neither Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Please indicate your overall satisfaction with your College experience outside of the residence:
❒
❒
❒
❒
❒
Very Satisfied
Satisfied
Neither Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Is there anything we could do differently to improve your overall satisfaction with your experience in residence or at the College?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Is there anything we could do to encourage you (or help you) stay in residence for the remainder of the semester/year?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
OFFICE USE ONLY
Withdrawal letter received:
____
/
____
/
____
Received by (Manager) ___________________________________________
MM
DD
YY
❒
❒
❒
Student contacted:
Yes
No
Refund processed:
Yes
Date student contacted:
____
/
____
/
____
Date refund processed:
____
/
____
/
____
MM
DD
YY
MM
DD
YY
Confirmed cancellation/move-out date:
____
/
____
/
____
MM
DD
YY
Reservation Number:
__________________
Room Type:
_______________________________________
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