Professional Documents
Culture Documents
LI
1308
Personal details
Course code (eg BS05)
Student number
Family name
Given name
Date of Birth (dd/mm/yyyy)
Town/suburb
State
Post code
Email
Documentation requirements
Please complete and submit this form along with documentary evidence
supporting your request. You can lodge this form at any Student Centre
counter or mail it to the address above. When lodging the form at a Student
Centre, please bring your passport, visa and QUT ID card. If you are mailing
the form to QUT, please attach certified copies of your visa and passport
and ensure that all other documentation provided is either the original or a
certified copy.
Supporting evidence includes documentation such as medical certificates or
statements from employers. It is your responsibility to ensure that all relevant
documentation is either an original or a certified copy. For more information
visit www.student.qut.edu.au/studying/special-circumstances
1. Visa type
Student
2. Leave of absence details (only complete this section if you are applying for leave)
Leave of absence
(see Section 4)
I request leave of absence (Intermission) from my studies in the above course from
........../........./.........
3. Course cancellation (only complete this section if you are cancelling your course)
I wish to cancel my course
If you are in a pathway program, please indicate below which courses you wish to cancel:
4. I wish to apply for withdrawal without penalty (please indicate where possible):
You may be eligible for withdrawal without academic and/or financial penalty or refund where you can demonstrate that special circumstances necessitated the withdrawal,
Academic penalty
Both
Course
code
Teaching
period
Year
Unit code
Census
WWAP
date date
If you have indicated that you wish to be considered for withdrawal without academic or financial penalty in Section 5, relevant documentation must
be provided to support your special circumstances.
Unit additions and withdrawal dates table can be accessed at www.student.qut.edu.au/about/key-dates-and-academic-calendar/key-dates
Relevant documentation required for Special Circumstances is listed at www.student.qut.edu.au/studying/special-circumstances
Privacy
Details of QUTs practices regarding student information and privacy see www.qut.edu.au/privacy If you are unable to access the internet, you can
contact QUT Student Centre in person, phone 07 3138 2000 or email askqut@qut.edu.au for this information.
6. Declaration
By submitting this application I agree to comply with the statutes and rules of Queensland University of Technology that apply to me. I further agree
that I am subject to and must comply with any policies or procedures of the University governing my conduct as a student, and academic matters
affecting my studies, including but not limited to, the QUT Student Code of Conduct www.mopp.qut.edu.au/E/E_02_01.jsp and the procedures for
management of student discipline www.mopp.qut.edu.au/E/E_08_01.jsp
I declare that to the best of my knowledge the information supplied by me is true, correct and complete in every respect. I acknowledge that the
submission of false, incorrect, incomplete or misleading information may result in delays in processing.
I acknowledge that I am responsible for the payment of all student fees and charges applying to my admission and study at QUT.
QUT shall not be liable for any failure to provide services (including lectures, tutorials or examination results) or any teaching or other materials to
students where such failure is due to circumstances beyond QUTs control. Such circumstances include, but are not limited to, natural disasters,
malicious damage, outbreak of pandemic disease, industrial action or strikes, acts of war or acts of God.
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............../............./..............
N/A
Student number
Yes
Course cancellation
N/A
Yes
Was the semester of study under consideration within the last 12 months? ..........................................................................
If not has documentation been provided?
Yes
Yes
No
No
(If NO, please do not complete this section. Advise the applicant that they are TOO LATE for consideration unless they can provide evidence why
they could not apply within the last 12 months.)
Yes
Medical
Course
No
Employment
Family / Personal
Uni error
Yes
Medical
Course
No
Employment
Uni error
WWFP Comment..................................................................................................................................................................................................................
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Managers
name ..........................................................................................Signature.........................................................Date............../............./..............
Please complete the table below. Ensure you enter all details and follow the checklist down FOR THAT UNIT, ticking all procedures as they are
completed.
C. WWAP / WWFP PROCESSING (tick as you complete).
Unit Code
1. If failed status (if enrolled, go to 2): unratify
and uncertify (ESR)
2. Change unit WD date to census + 1 (ESR)
3. Ratify results if required. (ESR)
4. Sponsor student YES/NO
If Yes refer to sponsorship officer
5. Fee (raised in Callista): process Remission
Pre-SAMS international student
6. Tuition fee (raised in SAMS): Pre-reporting
Sponsorship set up (SFC)
7. Tuition fee (raised in SAMS): Post-reporting
Student fee reversed (SFC)
8. REFUND Form submitted
Yes
No g
9. Comments in SAMS
ESR
SFC
ESR
SFC
Yes
Include in email
Amount ..................................