Special Circumstances Request Form

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Application for Special Circumstances form
Please use capital letters and print clearly when completing this form.
See reverse for instructions and additional information.
Before submitting your Special Circumstances Application Form, please ensure that you
have:
Read and understood the Instructions for Completing the Special Circumstances
Application;
Attached supporting documentation as outlined in Section 4 of the instructions
for Completing the Special Circumstances Application;
Completed all sections of the form and signed where indicated.
Section 1: Personal and Contact Details
Student ID:__________________________________
Title: (please circle) Mr Mrs Miss Ms Dr
Family Name: _____________________________
First Name:___________________________
Street name and number:
Suburb
State
Country
Postcode
Phone
Mobile
Email address
Section 2: Unit Details
Please include details about all units you have withdrawn from.
Please note that this is not the form you use to withdraw from units.
Unit Code
Unit Name
Payment method Study Period
Version
Internal
Page Number
Document Name
Application for Special Circumstances – LNQIF1037
January 2013
Unilearn
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