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Course Withdrawal Form

This form is to be used for online (distance) courses only.
All highlighted fields are required.

Surname
 First or Given Names
 Student Number

Email
 Phone Number

Mailing Address
 City
 Province
 Postal/Zip Code

Course Code
 Course Type
 Starting Date
 Percentage Completed

Reason for Withdrawal Request

Refund
Please process my refund (if any) by

Your withdrawal is effective the date this form is submitted

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