Student details

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

Type of request

(Please tick one)

Assessment Extension
Reassessment / Resubmission
Leave of Absence
Work Placement Support
Fee / Payment Plan Request
Academic Support
Other

Details of Request

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

Supporting Documents Attached

Medical Certificate
Evidence of Payment
Statutory Declaration
Other
Not 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: