May 1 2018
NAME OF APPLICANT:
ADDRESS:
TELEPHONE: EMAIL:
SESSION YOU ARE CURRENTLY ATTENDING: Fall Spring Summer
COURSE WITHDRAWAL
If a course withdrawal is requested after the first class, acknowledgement of the withdrawal is required from the Instructor of the course.
Course Name Course Code Course Instructor
Applicant Signature:
Date:
Instructor Acknowledgement: I am aware that the above named student is withdrawing from the course listed above. If applicable,
all course materials have been returned.
Name of Course Instructor:
Signature of Course Instructor:
Date:
Submit completed form to DDSB AQ Registrar by fax 905-666-6946 or email aq@ddsb.ca
FOR OFFICE USE ONLY
Date form received:
Number of classes attended:
Amount of fee refunded (if any): $
Registrar Signature: Date:
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