Office of the Registrar, Athabasca University
1 University Drive, Athabasca, AB T9S 3A3
Toll Free in Canada/US: 1.800.788.9041
Other: 780.675.6111
enrol@athabascau.ca
www.athabascau.ca
Course Withdrawal
Request Form:
Individualized Study
STUDENT ID NUMBER (if applicable)
FOR OFFICE USE ONLY
SPONSORING CLIENT ID NUMBER
REFERENCE NUMBER
Before you complete this form, review the AU Calendar,
Course Withdrawal – Individualized Study:
www.athabascau.ca/calendar/undergraduate/admission-registration-evaluation/
individualized-study-courses.html#course-withdrawal
and
Refunds: Individualized Study Course Tuition:
https://www.athabascau.ca/calendar/undergraduate/fees-refunds-and-financial-
assistance/refunds.html
General
Information
(please print)
Student Name: _____________________________________________________________
LAST FIRST MIDDLE
Mailing Address: _____________________________________________________________
_____________________________________________________________
CITY/TOWN PROVINCE/STATE
_____________________________________________________________
COUNTRY POSTAL/ZIP CODE
Telephone: (_____)_______________________(_____)__________________________
(AREA CODE) RESIDENCE
(AREA CODE) SECONDARY
Email: _____________________________________________________________
EMAIL
Course
Information
If you are withdrawing outside the
30-day refund period, it is still important
that you complete and submit this form.
Students may not withdraw from a
course once the nal examination has
been written or after all course work
is deemed to have been submitted
for marking (for courses that do not
have a nal exam requirement) or
after the course contract end date.
Practicum courses have special with-
drawal requirements—please see the
Undergraduate Calendar at www.atha-
bascau.ca/calendar/undergraduate/
admission-registration-evaluation/indi-
vidualized-study-courses.html#course-
withdrawal for more information. If you
qualify for a refund, your request will be
processed within 45 days of submitting
your withdrawal request.
I wish to be withdrawn from the following course(s):
Course name and number Start date End date
______________________ _____________________ ____________________
______________________ _____________________ ____________________
______________________ _____________________ ____________________
The date of your withdrawal will be recorded for your academic record.
Refer to page 2 for mailing instructions.
r 1. I am withdrawing prior to, and up to 30 days after, the course contract start date.
r I am withdrawing within 30 days of the course contract start date AND I am
also requesting a refund* of my Learning Resources Fee, provided:
• my learning resources are returned to AU within 30 days of my withdrawal
notice;
• all the materials are undamaged, unmarked, reusable, and included software
has not been opened, and;
• all costs related to the return of the learning resources have been prepaid by me.
Note: if the Learning Resources for the course are eTexts, the student does not
need to do anything further than filling out and submitting this form. The refund
will be automatic if the withdrawal is received within the 30-day withdrawal period.
r 2. I am withdrawing 30 days after the course contract start date but on or before
the course contract end date. I understand I will not receive a refund.
Note: Students cannot withdraw after the course contract end date. If no course
work has been completed and you have not withdrawn from the course, a grade
of “F” (Failure) will be assigned and recorded on the transcript. No refunds will be
given.
* Course Material Return and Refund Policy: www.athabascau.ca/university-
secretariat/_documents/policy/course-material-returns-refunds-policy.pdf
Student signature:___________________________________________ Date: _____________________
Pg 1 of 2
The personal information collected on this form will
be used to process your application to withdraw
from a course. This information is collected under
the authority of section 33 (c) of Alberta’s Freedom
of Information and Protection of Privacy Act. If you
have any questions about the collection and use of
this information, please contact the Coordinator,
Enrolment Services, Office of the Registrar, Atha-
basca University, 1 University Drive, Athabasca, AB
Canada T9S 3A3. Phone: 800.788.9041.
click to sign
signature
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