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Withdrawal form_Present_edited

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39 views3 pages

Withdrawal form_Present_edited

Uploaded by

Balqisjamaludin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Withdrawal Form

(Please submit this form together with “Change of Programme Status Survey” Form to the Student Affairs
department.)

SECTION A: STUDENT PARTICULARS

Name: _____________________________________________ Student ID: _____________________________


Programme: _________________________________________ Year: __________________________________
NRIC/Passport No.: ____________________________________ Contact No.: _____________________________
Email.: ______________________________________________________________________________________
Current Address: _____________________________________________________________________________
Withdrawal effective from: ____________year_______________sem

SECTION B: GUARDIAN DETAILS

Guardian name: ______________________________________________________________________________


Relationship with Applicant: _____________________________________________________________________
Email.: _______________________________________________ Contact No.:____________________________
Current Address: _____________________________________________________________________________

SECTION C: WITHDRAWAL PARTICULARS


(Please state your reason after withdrawing from this programme)

College Withdrawal Programme Deferment


Transfer to affiliated school Leave of Absence
Financial Personal
Medical Condition

Others
(Please state the reason:)
_____________________________________________________________________________________________

_____________________________________________________________________________________________

SECTION D: WITHDRAWAL CONDITIONS AND INSTRUCTION


(Please read carefully the term and condition)
Conditions:

 When all the withdrawal applications are completed, the student will be withdrawn. Students are not
allowed to retract their application.
 As a general rule, paid fee will not be returned.
(In the unlikely event that there is a refund, the school will transfer it to the account designated by the
student. The fee will be borne by the student.)
 In case of late payment, student cannot withdraw from school until all payments have been settle.
 Student need to return the borrowed equipment (books, equipment, etc.) by the designated date. If it
cannot be returned, student will be required to reimburse the cost.
 If there are any personal data or belongings stored on the school PC, students are required to take them
home by the day they leave school.

Instruction:
(Please follow the instructions below)

1) Please inform staff at the reception counter that you wish to withdraw. A consultation will be conducted.
2) After consultation, the form will be given by the staff in charge and student may apply for withdrawal.
3) Students are expected to return their student ID to the staff in charge and equipment that are borrowed during
the study period.
4) The school will inform the results of the application through email.
SECTION E: BANK ACCOUNT DETAILS
(Please provide bank account details in case of refund.)
Please Specify the payment option for refund (Subject to bank charges)

By Cheque Crossed / Open Cheque

Bank Transfer

Bank:
________________________________________________________________________________________
Bank account name:
____________________________________________________________________________
Bank account no.:
______________________________________________________________________________

Please specify payee for refund:


Self
Family Member Father / Mother / Guardian

Name : ______________________________________________________________________________________
NIRC: _______________________________________________________________________________________

SECTION F: APPLICANT DECLARATION AND SIGNATURE

I hereby declare that all information that has been provided in this application form, including any information
from supporting documents submitted with this form, is complete and legitimate. I also accept that NDS Malaysia
reserves the right to disqualify the application made on the basis that incorrect, incomplete, or fraudulent
information.

Applicant’s Signature: ___________________________________ Date: ____________________________


If applicant is under 18 years of age at the time of application submission, a parent or guardian’s signature is
required to sign this declaration on their behalf.

Guardian’s Signature: ___________________________________ Date: ____________________________l


Guardian’s Name:
_________________________________________________________________________________

FOR OFFICE USE ONLY

Date Application Receive : ______________________________________________________________________

Officer’s Name : ______________________________________________________________________


Officer’s Designation : ______________________________________________________________________

NDS office stamp Date of approval: __________________________

Please confirm the student’s status and sign.

Library division : ___________________________ Date :


_________________________________

IT division : ___________________________ Date :


_________________________________

Finance division : ___________________________ Date :


_________________________________

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