Student Request Form

Student details

Student ID:
Full Name:
Course Name:
Email Address:
Mobile Number:

Type of request

(Please tick one)

aaa
bbb
ccc

Type of request (if other ):

Details of Request

Please clearly explain your request and provide relevant details (unit code, assessment name, dates,
etc.).

Supporting Documents Attached

Medical CertificateEvidence of PaymentStatutory DeclarationOtherNot Applicable

Student Declaration

I declare that the information provided above is true and correct. I understand that my request will be processed
within 10 working days. I also acknowledge that urgent requests attract a non-refundable administrative fee of AUD
$100. I understand that submitting false or misleading information may result in rejection of my request.

Name:
Signature:
Date:

Office Use Only

Received by:
Date Received:
Authorised By: