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COMPLETION/WITHDRAWAL FORM
1. APPLICATION PARTICULARS
Name : Student ID :
Programme : Contact No. :
Mailing Address :
Email address :
I hereby officially request to withdraw from the above programme with
effect from ________________ (dd/mm/yyyy). I would be considered a
new student, should for any reason, I re-enroll with UCSI University for any __________________
programme, and will have to pay all relevant registration fee, deposits and Signature of student
tuition fee.
Date:
2. REASON FOR WITHDRAWAL
Completed programme
Going on-campus (please specify University)
Academic issues (please specify issue)
Financial issues
Joining another university (University)
(please specify University & programme)
(Programme)
Other reasons (please indicatee)
3. MODE OF PAYMENT
Cheque – payable to ____________________________________________* (Name as per I/C or Passport)
Please mail to my above address**
Please hold cheque for my collection***
Telegraphic Transfer (for overseas accounts and international students only)
Beneficiary :
Account Number : Name of bank :
Bank Address :
Swift Code : IBAN Code (if any) :
* If refund is made payable to other party, please provide an authorization letter. For international students, please also attach a copy of passport for both the
applicant and authorized person.
** Cheque will be posted via normal mail 1 month after the expected date of cheque release. The University is not responsible for lost of cheque in mail
***Please note that validity of cheque is only six(6) months from the date of cheque issued.
RM25.00 will be charged as replacement fee if you fail to return your Student ID Card
All bank charges will be borne by the applicant. Upon completion of this page, please see the departments concern
(UCSI-RO-010) Last updated: August 2014
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4. CLEARANCE & EXIT INTERVIEW
Kindly get the necessary clearance from each of the departments/faculty.
1. Library
The student has returned all the books borrowed
Please deduct RM_________ as cost of replacement for:
a) _______________________________________ RM_______ Signature of Chief
b) _______________________________________ RM_______ Librarian or designate
c) _______________________________________ RM_______ Name:
d) _______________________________________ RM_______ Date:
2. Academic Division (Faculty/Institute)
Has the student been interviewed? Yes No
Remarks: Signature of Head of
________________________________________________________________ Programme or designate
Name:
________________________________________________________________
Date:
________________________________________________________________
3. Student Affairs and Alumni Division
I would like to contribute RM50.00 to the UCSI University Alumni
Association. Please deduct it directly from my refundable deposit.
Signature of Head of
Accommodation Services Department Department or designate
No outstanding of fee Name:
Outstanding of fee – Please deduct RM_______ as cost of replacement Date:
4. International Office (only applicable to international students)
This is to confirm that the International Office has received the below
documents for the cancellation of visa:
A copy of student visa
Student visa expiry date: _________________
A copy of air ticket Signature of Head of IO
Passport or designate
Name:
Remarks: _______________________________________________________ Date:
(UCSI-RO-010) Last updated: August 2014
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5. FOR GROUP FINANCE USE ONLY
Amount to be refunded RM Checked by: Confirmed by:
Caution Fee
Library Deposits
International Student Deposits
International Student Bond
Completion Fee Deposit – Postgraduate
Total: Finance Office
Less – Cost of Replacement RM Checked by: Confirmed by:
Library Book(s)
Student ID
Tuition Fee
Damage Report
Alumni Fund
Other Offense(s)
Amount to be refunded: Accounts Office
Cheque Number: CIMB__________
Received and updated by:
_____________________
Name:
Date:
6. RECORDS OFFICE
Student file checked and scanned on: _____ - _____ - __________
(date) (month) (year)
Student file closed on: _____ - _____ - __________ Authorized Signature
(date) (month) (year) Name:
Date:
7. ACKNOWLEDGEMENT SLIP
This is to acknowledge receipt of the Programme Withdrawal Form from:
Student Name: ________________________________________________
Authorized Signature
Student ID:_______________ Stamp: Name:
Date:
(UCSI-RO-010) Last updated: August 2014
