OFFICE OF THE UNIVERSITY REGISTRAR
Mailing Address: P.O. Box 1796 • Edmonton, Alberta, Canada T5J 2P2
Phone: 780-497-5000 • Toll Free: 1-888-497-4622
www.MacEwan.ca • E-mail: recordsunit@macewan.ca
FREEDOM OF INFORMATION & PROTECTION OF PRIVACY
Protection of Privacy - The personal information requested on this form is collected and protected under the authority of Part 2 of the Alberta Freedom of Information and Protection of
Privacy Act and the Post-Secondary Learning Act. It will be used for the enrollment process and student management consistent with that purpose. This information will be entered into and
retained in the ofcial university student information system database. Direct questions expressly related to the collection and use of this information to the Associate Registrar, Records,
Ofce of the University Registrar, MacEwan University, 10700-104 Avenue, Edmonton, AB, T5J 4S2, telephone 780-633-3110.
PROGRAM WITHDRAWAL NOTICE FORM
PERSONAL INFORMATION
WITHDRAWAL
STUDENT ID NO.: FAMILY (LAST) NAME: FIRST NAME: MIDDLE NAME:
PROGRAM:
TERM: FALL WINTER
SPRING/SUMMER
YEAR:
__________
Reason for withdrawal:
_____________________________________________
SIGNATURE - DEPARTMENT CHAIR/DESIGNATE:
________________________
SIGNATURE - STUDENT: _________________________________________
DATE: _________________________
PROGRAM CONSULTATION
OFFICE USE ONLY
CURRENT TERM: BALANCE DUE: $_______________________
REFUND: $ ____________________________
TOTAL BALANCE: $ ____________________
PERSONAL INFORMATION COLLECTION NOTICE
The personal information requested on this form is collected under Section.33(c) of the Freedom of Information and Protection of Privacy Act for the purpose of one or all
of the following: to determine eligibility for admission and financial assistance, to advise students about academic programs and to provide university services at MacEwan
University. Questions concerning this collection should be directed to the Lead, Privacy and Information Management at privacy@macewan.ca
International students are encouraged to discuss withdrawals with an international student advisor to ensure they are aware
of the impacts withdrawing may have on their study permit compliance and/or future immigration program eligibility.
Refunds, if applicable, will be processed according to the Refund of Tuition and Student Fees Policy.
International students must inform Immigration, Refugees and Citizenship Canada (IRCC) if they are transferring
Designated Learning Institutions (DLI). This can be done through the myCIC portal.
SIGNATURE - INTERNATIONAL ADVISOR: _______________________________________
DATE : _______________
SIGNATURE - STUDENT:______________________________
DATE: ______________________
INTERNATIONAL STUDENTS ONLY
By submitting and signing this form, you are forfeiting your seat in your program. Reinstatement is not possible. If you intend to
return, you will be required to submit a new application and meet the applicable admission requirements.
Withdrawal will be processed effective the date this form is received at the Office of the University Registrar.
DATE:
Students are encouraged to discuss withdrawals with their program Advisor or Department Chair.
Program Comments:
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
ARE YOU AN INTERNATIONAL STUDENT?
YES NO
FEES PROCESSED BY: _____________________________
DATE PROCESSED: _____________________________
RECORDS - PROCESSED BY :___________________________________________
DATE PROCESSED: _____________________________
N/AOWING REFUND
*Required
*Required
