Sunteți pe pagina 1din 3

WITHDRAWAL FORM

NOTIFICATION OF WITHDRAWAL FROM THE UNIVERSITY


NOTIFICATION OF COMPLETION OF PROGRAMME FROM THE UNIVERSITY

Please complete all sections on this form and read the policy overleaf before submitting this form to Registrars Office.
SECTION A: PERSONAL AND ACADEMIC PARTICULARS (Please the appropriate box)

Name: Student ID:


(As in MyKad/Passport)

MyKad/Passport No: Scholar ID:

Programme: Intake:

Contact No: Email:

Student Type: Local International Notification: Withdrawal Completion of Programme

SECTION B: REASON(S) FOR WITHDRAWAL / COMPLETION OF STUDIES (Please the appropriate box)

Obtained offer from other University Completion of Studies Transfer to other University

Other reasons (please specify):

SECTION C: ACKNOWLEDGEMENT BY REGISTRAR

Remarks:

Signature & Stamp: ______________________________________________ Date:

SECTION D: VERIFICATION FROM SCHOOL / CENTRE

Commencement Date: _______________________________ Termination/Completion Date: _____________________________

Signature & Stamp: _____________________________________________ Date:

Remarks:

SECTION E: CLEARANCE FROM LIBRARY (Please the appropriate box)

Lost library item(s): Yes No Library fines: Yes No Student has overdue item(s): Yes No

If Yes, please state the total amount due + processing fees (RM10): _________________________________________________

Librarians Signature & Stamp: _____________________________________________ Date:

Remarks:

SECTION F: CLEARANCE FROM STUDENT AFFAIRS MANAGER - HOSTEL (Please the appropriate box)
(please return the keys to the room and unit together with the hostel clearance form)

Unit Number: ___________________ Room Number: ____________________ Checked-out date: ______________________

Signature & Stamp: _____________________________________________ Date:

Remarks:

The Registry RO/WF&CF/012014/v2


SECTION G: CLEARANCE FROM INTERNATIONAL OFFICE for International Students only (Please the appropriate box)

Verified passport (for cancellation of student pass)

Signature & Stamp: ______________________________________________ Date:

Remarks:

SECTION H: CLEARANCE FROM REGISTRAR & ADMISSION (Please the appropriate box)

Cancelled Student ID card (student to surrender their Student ID Card)


Updated students status in CMS

Signature & Stamp: ______________________________________________ Date:

Remarks:

SECTION I: REFUND PARTICULARS (Please the appropriate box)

Please specify the type of payment for refund: Refund of Fees Refund of Deposits
Please specify the payment option for refund: Bank Draft (Overseas bank) Crossed Cheque (Local bank)
Please specify the payee for refund: Self
Father Mother Guardian

Name:
MyKad/Passport No.:
Please specify the collection method for refund: Collect personally or by the payee
Post by mail to the address below

Address :

City: ______________________________ Postcode:

State: Country:
Collect on behalf (Note: A letter of authorisation is required)

SECTION J: FINANCE

Amount to be refunded (please itemise) Caution Fee RM

Personal Bond RM

Tuition Fee RM

Hostel Deposit RM

Sub Total RM

Penalty Deductions (if any) RM

Sub Total RM

Refund Grand Total RM

Processed by: Signature & Stamp: _________________________________ Date:

The Registry RO/WF&CF/012014/v2


Withdrawal from University

1. If students wish to withdraw from a program, they must submit a written application
(Notification of Withdrawal from the University form) obtainable from the Admissions
Office to the Dean. A request for withdrawal from a program will be treated as a
request for withdrawal from all subjects.

2. The application for withdrawal must be accompanied by their identification card.

3. The official date of withdrawal is the date on which their withdrawal form is received by
MIU even if students have stopped attending lectures earlier.

4. Students are liable to pay all fees due to MIU for the new semester even if they do not
attend classes without notifying MIU of their withdrawal. Students will be withdrawn
from MIU.

5. All books and other facilities borrowed from MIU must be returned. MIU entrusts
students with this responsibility. Their failure to do so will result in withholding of all
refundable deposits including the Caution Fee.

SECTION K: DECLARATION AND SIGNATURE

I hereby declare that all information provided by me in this form is accurate and I agree to the above terms and
conditions.

Student Name : ______________________________________________

Student Signature: ______________________________________________

Date : ______________________________________________

The Registry RO/WF&CF/012014/v2