MEDICAL CERTIFICATE FOR A DEFERRED (DEF) NOTATION
4B
Office of the Registrar
Date
Concordia I.D. #
Name
Family Name
Telephone: Home (
)
Given Name
 Cell
 Work (
Area Code
E-mail
Address
)
Area Code
A Deferred Notation is requested for the _____________________ academic year and session (e.g. 2010/1, 2010/2, 2010/3, 2010/4),
for the following course(s):
COURSE NAME
e.g. ACCO
COURSE NUMBER
213
SESSION
2
SECTION
AA
COURSE NAME
e.g. ACCO
COURSE NUMBER
213
SESSION
2
SECTION
AA
_______________
___________
_________ _________
_______________
___________
_________ _________
_______________
___________
_________ _________
_______________
___________
_________ _________
_______________
___________
_________ _________
_______________
___________
_________ _________
Deferred “DEF” notation indicates that a student has been unable to write a final examination due to unforeseeable circumstances
beyond the student’s control. For short-term medical situations, this form must be submitted in support of your request.
1. You must visit your medical practitioner on or before the date of the missed exam.
2. By submitting this note, be advised that you authorize us to verify its legitimacy.
3. Tampering, altering or modifying the certificate in any way could lead to charges brought against the student under the Code of Rights and
Responsibilities and/or the Academic Code of Conduct.
This section MUST be legible and completed by a licenced medical practitioner only.
The above-mentioned student was seen for a medical condition on
Date
The student is/was not able to write his/her exam(s) on
Date
Was this serious illness/injury predictable/foreseeable?
 YES
 NO
How did this serious illness/injury prevent the student from writing the exam(s)?
M.D.’s Name
Please print
Telephone
Licence/Registration No.
Date
Signature
M.D. / Hospital / Clinic Stamp
UES410 73100
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