Deferral Suspension Cancellation Withdrawal (DSCW) Form

Deferral Suspension Cancellation Withdrawal (DSCW) Form
Section 1 - Client Details
Student ID *
GLEXXXXXX
Name: *
Contact Tel:
Mobile: *
Email: *
example@example.com
Course Currently Enrolled: *
Course Start date:

Day Month Year
Course End date:

Day Month Year
List Other courses, if in case you are applying for Cancellation and withdrawal

(Otherwise, leave blank)
Course Currently Enrolled:
Course Currently Enrolled:
Course Currently Enrolled:
Section 2
Please select your reason for your application *

Deferment Suspension Cancellation Withdrawal
Date effective from:

Day Month Year
Till: (if applicable)

Day Month Year
Section 3
Evidence Provided *

A letter from a registered Medical Practitioner due Sickness. Evidence for the family emergency, if cited as a family reason. Appropriate evidence for compassionate grounds If traveling overseas, attach a copy of travel tickets Other
Cancel of
Section 4 – Reasons
Reason: *
Student Declaration
I understand that: *

The application will be considered in accordance with Glen Institute’s Deferral Suspension Cancellation Withdrawal Policy My deferral will be subject to course availability. I understand the implications of my student visa I have attached all required supporting documentation I will notify Glen Institute in writing if my circumstances change If the matter pertains to Deferment / Suspension, this will be reported to Department of Home affairs as per Government Policy. This can affect a student’s visa and I am aware that under such circumstances, I need to contact Department of Home affairs on 131881 if I need more information on this. My Fee payment is up to date. Signing this form does not mean that it is approved, you need to wait for Glen Institute's approval communication.
Signature *

Clear
Date *

Day Month Year
Date
Finance Approval
Request approved by finance Yes No N/A Date Date
Print Name: Signature Signature
Section 4 - Authorisation
Requested Change has been approved:

Yes No
If No, provide reason below:
Signature *

Clear
Position
Print Name:
Date Processed:

Day Month Year
Date
Admin Use Only
Changed in Accounts

Yes No N/A
Date

Day Month Year
Date
Staff Initials
Changed in SMS:

Yes No N/A
Date

Day Month Year
Date
Staff Initials
Changed in PRISMS:

Yes No N/A
Date

Day Month Year
Date
Staff Initials
Formal Letter/Email Sent:

Yes No N/A
Date

Day Month Year
Date
Staff Initials
Sent by:
Signature

Clear
Should be Empty:

Deferral Suspension Cancellation Withdrawal (DSCW) Form

Section 1 - Client Details

List Other courses, if in case you are applying for Cancellation and withdrawal

Section 2

Section 3

Section 4 – Reasons

Student Declaration

Finance Approval

Section 4 - Authorisation

Admin Use Only