Payment Instalment or Fee Extension Request Form

Payment Instalment or Fee Extension Request Form
Details
Student ID Number: *
Name *
Email *
example@example.com
Course: *
Group No:
Course start date:

Day Month Year
Date
Section 1 – Student to complete
I request an extension for payment of the following:
Invoice Number:
Amount:
Reason: *
(Please attach any supporting documentation)

Cancel of
How and when you want to pay: *
Failure to make a payment on the adjusted date will incur additional late fees as per the fees policy.
Section 2 – Student Declaration
*

I understand that my application for an extension on fee payment will be processed in accordance with Glen Institute Student Fees and Charges Policy. Signing this form does not mean that it is approved, you need to wait for Glen Institute's approval communication.
Print name: *
Signature: *

Clear
Date *

Day Month Year
Date
Financial Officer Authorisation
Authorisation for Processing

Approved Denied Adjusted amount
Extension Date:
Comments:
Signature

Clear
Position:
Print Name:
Date Processed:

Day Month Year
Date
Should be Empty:

Details