Singapore Polytechnic

SINGAPOREPOLYTECHNICSubmit personally at:Student Service CentreBlock 16, Level 1 (T1612)or Mail to:Singapore PolytechnicAdmissions Office500 Dover Road, Singapore 139651NOTIFICATION OF WITHDRAWAL FROM COURSEThis form may take you 2 minutes to fill in. The data provided to Singapore Polytechnic will be1. Refund Policy: For withdrawals received before the commencement of term in semester 1 or 2,students may obtain a refund of tuition fees paid for that semester less an administration fee of $50 forDiploma and $100 for all other courses. For withdrawals received within the 1st week of semester 1or 2, a 75% refund of tuition fees paid for that semester may be granted. For withdrawals receivedafter the 1st week of semester 1 or 2, there will be no refund or carrying forward of fees paid.There will be no refund for Virtual College (VC) students after the commencement of the semester.There is no refund on Students' Union fees, Insurance fee, Freshmen orientation package, CLASS feeand Registration fee.2. Payment Policy: Students withdrawing after the start of the semester are liable to pay fees. Any nonpaymentof fees will be noted.3. Students are not allowed to withdraw during the official examination period. For anywithdrawals received upon the start of and during the conduct of the semestral exam, thestudent will be considered to have sat for the exam and may be removed. If the student isnot removed, the withdrawal date will be post-dated to the day the semestral results arereleased.4. The Singapore Polytechnic reserves the right to take any appropriate action it deems necessary where a... ... . . . - ...1. Students must return all property belonging to Singapore Polytechnic and settle all outstanding billsprior to the submission of this form.2. Students under 21 are to obtain their parent's I guardian's signature. Full-time students are also toobtain their Director's signature. All students must proceed to the Library and finally to Student ServiceAdmission No: ______ _ NRIC: ------- Age: __ Tel (H) : -------NameTel (0) : ______ _Course: (FTIEOIDR/VC)*Handphone.: --------AddressReason for Withdrawal: "Reason Code"(refer to the codes given behind)I declare that: a. I have read, understood and agree to abide by the above regulations & procedures.b. The information I have provided is true and accurate to the best of my knowledge.c. My Student Card is returned I is lost I was not issued*.d. Library books: I have returned 1 have not returned 1 reported lost to the Library I didnot borrow*.e. My ez-link card (full-time students only): I have returned I not returned I reportedlost to Transitlink's Card Replacement Office*.f. Non-Singaporeans: I will return my Student Pass to Immigration & CheckpointsAuthority (ICA) within 7 days.DateI am aware of and support my child'slward's withdrawal from the Polytechnic course.Lib Books: ((() returned) not returned) reported lost(For full-time students only)SERVICE CENTRE( ) returned( ) not returned( ) reported lostDateRelease 6.2

Reasons for WithdrawalCategory Reason Reason CodeCan't Cope with Course Cannot cope with the course ccEmployment Work commitments WKGoinq to work overseasowFamily Family problems FGParent illPAHelp in family businessFBFinancial difficulties #FDJoining Other Institutions Goinq to study overseas OSJoininq Ngee Ann PolytechnicNPJoining Nanyang PolytechnicNYJoining Republic PolytechnicRPJoininq Temasek PolytechnicTPJoininq Pre-University/Centralised InstituteCIJoining Junior CollegeJCJoining ITE/EDB Training CentreTIJoining University Programmes locallyUNLost Interest Lost interest in the course LIMedical Medical (General) MOMedical (Mental)MMDeceasedMDNational Service Called up for National Service FNOthers Disciplinary Action DIEmiqratedMIReturn to Home CountryRHOther reasons not listedOTCommitted crime (Convicted)CRPlease note:# Full-Time students withdrawing on financial or medical grounds should consult the StudentCounsellor for advice. Students withdrawing on financial grounds should consider applying foran interest free Polytechnic loan. Further information is available from the Student Counsellorat the Student Service Centre.Note:1) Students who have been paying their fees by GIRO should submit their Bank's relevant'termination form' to their Bank to cancel their GIRO payment order.2) Students who wish to re-enrol in subsequent years, are required to apply for admissionwhen applications open for that year.AS-FRM-104B Page 2 of 2 Release 6.2