(HIGHER EDUCATION ONLY)
WITHDRAWAL AND REFUND APPLICATION FORM
1. APPLICATION TO WITHDRAW
2. APPLICATION FOR WITHDRAWAL AND REFUND
3. APPLICATION FOR REFUND UNDER COMPASSIONATE AND COMPELLING
CIRUCUMSTANCES
Please refer to the Higher Education Refund Agreement for conditions under which a refund will be granted
Student Identification Number
Postal Address
Residency Status
Domestic
International
(Please select one)
Family Name:
Contact details
Mob:
Given Name:
Phone:
Email:
Application Type
I wish to (Please select one)
Withdraw from unit (s)
Apply for withdrawal and refund
Apply for withdrawal and refund under compassionate
and compelling circumstances
International students please note that
your Visa may be affected as a result of a
withdrawal. Contact your International
Student Advisor or DIAC for further
information before submitting this form.
Course and Unit Information
The course and units relevant to this application include
Course Code:__________________________________
Course Name:_______________________________
Year
Unit Code
Study Period
Unit Title
Reasons for your application
© North Metropolitan TAFE 2016
Version 2.1
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COMPULSORY: Please provide detailed reasons for your application. If you require more space, please attach a
separate sheet. Please include independent, original or certified documentary evidence in your application (e.g
medical certificate, letter from counsellor, letter from employer).
Account Details
Bank Details for Refund
OR
Details for Credit Card Refund
(local and International Banks)
(Fees paid via credit card will be refunded to that account)
Bank Name:
Credit Card Holder
Bank Branch
Credit Card Type
Bank Address
(No P.O Box):
Credit Card Number
BSB Number / SWIFT Code
and /or IBAN Number:
Expiry Date
Account Number:
Signature of card
Holder
_ _ _ _/_ _ _ _ /_ _ _ _ /_ _ _ _
Account Holder Name:
Are there any attachments to this form? ____________How many pages are attached?______________
Declaration
I have read and understood the Higher Education Refund Agreement
I hereby certify that the information provided in this application is correct.
I authorise North Metropolitan TAFE to gather and obtain any necessary information
pertaining to this application based on the supporting documentation provided.
Print Name
_____________________________________
Signed
____________________________________ Date____________________________
© North Metropolitan TAFE 2016
Version 2.1
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