Term 1 Term 2 Term 3
Course name
CRICOS Provider Code: 00219C, RTO Code: 40939
QDAN 601.3/C10 – Retain for 6 months after last action
Course content did not meet expectations
Work commitments
Transferred to another University
Medical grounds (provide evidence)
Financial reasons
Poor customer service
Other (Please specify)
Effective: 27/02/2020
Student Number
Family Name
Given Names
Course Code
Current Campus
Future mailing address and contact details
Telephone number
Cancellation effective from:
Students are required to drop all units via MyCentre prior
to submitting the Cancellation of Course form. You will incur Financial and Academic penalties for
the term,
if you are cancelling your course after the last day to drop (i.e. census date).
Please refer to the relevant Calendar of Principal Dates ( and the Student Refund and Credit Balance
Policy and Procedure (
To help the University provide the best possible service, your comments and reasons for course cancellation would be appreciated. International
students must state the reason for cancelling their course as CQUniversity is obliged to report this information to the Department of Home Affairs (DHA).
Please indicate if this is your first year of study
Has an exit interview been conducted?
International Student
Current Metropolitan campus student (Sydney, Brisbane, Melbourne and Perth).
You are required to attend an interview.
Please return this form to your relevant campus.
Current Regional campus student (Rockhampton, Bundaberg, Gladstone, Mackay, Townsville and Cairns).
An interview will be arranged
. Please return this
form to or Building 65, CQUniversity, North Rockhampton, QLD, 4702.
Offshore student yet to commence.
Stat Dec and interview are not required.
Please return this form to
Domestic Student
Australian full fee paying or Commonwealth Supported and HECS-HELP student.
Please return this form to or
Building 65, CQUniversity, North Rockhampton QLD 4702.
Personal information is collected, used and stored by CQUniversity to facilitate your studies and related activities. Commonwealth and state departments require certain
information about student details and activities to be reported or disclosed by the University. Any other provision of your information will only be as authorised by you or required by law and in accordance with the
Information Privacy Act 2009 Qld and the University’s Information Privacy Policy and Procedure.
Applicant’s signature
Only current International students to complete this section:
Is a statutory declaration included?
Delegate signature
MAP: Yes No Under enrolled: Yes No
Office use only:
International student:
Completed 6 months: Yes
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