_______________________________________________ _________________________________________
_______________________________________________ _________________________________________
Continuing Education Course Withdrawal/Request for Refund
F
ax: 919-536-7277
To be completed only by Student (except in the case of cancellation)
INSTRUCTIONS: Print clearly all of the information required to complete the form. Sign, date, and return this
completed form to an official college representative.
Name ____________________________________ Course Number _________________________________
Student ID No. ______________________________ Course Title ______________________________________
Daytime Telephone Number ___________________ Courses Beginning Date _____________________________
Mail refund to: ☐ Student ☐ Employer__________________
Mailing Address: ________________________________________________________________________________
City _________________________________ State _________________ Zip __________________________
Reason for Withdrawal _______________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________________
I certify by signature my withdrawal from the above listed course and request a refund of registration fees paid as
permitted by the college refund policy.
S
tudent Signature Date of Request
Accepting Staff Signature Date / Time
DO NOT WRITE BELOW THIS LINE – For Office Use Only
Course Number ____________________________ Amount $ _____________________________
Request Approved: Request Not Approved:
☐ 75% Refund Due ☐ Past Deadline
☐ 100% Refund Due ☐ Other ______________________________________
☐ Transfer to Another Course
☐ Other ____________________________
Entered By ____________________________ Date ______________ Total Amount $___________________
Revised 3/2017
