Medical Application for June 2011 Exam Session

Important notes
1. Please note that the internal procedure of dealing with medical cases is complex and time taking.
2. The fee will only be deferred into students account once the entire procedure is undertaken and
completed with the satisfaction of ACCAs requirements.
3. The procedure does not automatically enter student for next examination session. Therefore, this
is students responsibility to submit the exam entry form in order to sit papers in the next exam
session.
4. Application without complete doctors declaration will not be accepted.
5. The deadline to submit the fee deferment request is 15 July for June examinations and 15
January for December examinations.

Name of the Student: ______________________________________________

Registration Number: _________________________________________
Reason: ___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Duration of sickness:
Day: __________
To
Day: __________

Month: __________ Year: ____________

Month: __________ Year: ____________

Date of Medical Certificate:

Day: __________

Month: __________ Year: ____________

Name of Doctor: ________________________________________________________

Name of Clinic / Hospital: ________________________________________________
Papers Enrolled for: _________________________
Papers Requested for Deferment: _________________

Undertaking: I declare that the information I mentioned above is true and correct upto the best of my
knowledge and belief. Incase of any fraud or dishonesty, I will be liable to disciplinary action.

____________________________
Signature of Student

_______________
Date