PROGRAM WITHDRAWAL FORM

Application Withdrawal
Students denied a Study Permit must provide the institution with this completed form and documents prior to the
expiration date given on the Letter of Acceptance. Authorized withdrawals are subject to a $200.00 administrative fee as
well as the $150.00 non-refundable application fee. All other monies will be refunded upon receipt of the required
documents.

Refunds after the program of study starts

Please refer to the policy stated on the back of your enrollment contract. Students who have remaining tuition deposit
balances after completing one or more terms are subject to a $200.00 administration fee when requesting a refund.

PERSONAL INFORMATION
Last Name: ________________________ First Name: ________________Student #: ___________
Student’s Address: _______________________________________________________________________
Prov. /State: Country: Postal Code:
Phone#: Email:

WITHDRAWAL REQUEST
Will you complete the current term? Yes No
Reason for withdrawal:
Attending another college – (please indicate school): ________________________________)
Financial issues
Denial of Study Permit (please attach a copy of the letter)
Other - Details: __________________________________________________________
Student’s Written Request:

Student Signature: Date:

FOR OFFICE USE ONLY: Withdraw term:______________ Refund form received: YES NO

Withdrawal form received by: Admissions Enrollment Services Date: ______

Reviewed by: _____ Date: ______

Refund applicable: YES NO Amount to be refunded: $ ______

For Visa Rejected, letter of rejection verified: YES NO Verified by: _________________________

ACSENDA Program Withdrawal From DFS/FORMS/Students

 REFUND FORM
Students are eligible for refunds of Overpayment of Tuition Fees, Credit on Account and Tuition Deposits in cases of
Visa/Study Permit denial. This form must be completed and signed by the student. A third party may not apply for a refund
on the student’s behalf. All payments made by credit card will be returned to the card from which the payment was made.
Please refer to the ASM refund policy for information on refunds at www.Acsenda.com.

PERSONAL INFORMATION
Last Name: ________________________________ First Name: __________________Student #: _____________
Student’s Address: ____________________________________________________________________________
Prov /State: Country: Postal Code: _______________________
Phone#: Email: ______________________________________________
Reason for Refund Withdrawal Visa Rejection Overpayment Other: _______________________

REFUND INFORMATION
Bank details: Wire Transfer Electronic Funds Transfer (CAD accounts only)
Name on Bank Account (Beneficiary): _________________________________________________________
Beneficiary Address: _______________________________________________________________________
Prov./State: ____________________ Country: ___________________ Postal Code: ____________________
Name of Bank: ___________________________________________________________________________
Account Number: __________________________________ Swift Code: _____________________________
Does your bank accept Canadian Funds for deposit to your account? (If no, payment in USD) YES NO
Credit Card Refund details:
Name of Account holder (as it appears on the card): __________________________________________________
Credit Card number______________________________________ Expiry Date (mm/yy)_________________

ADDITIONAL INFORMATION
Authorized refunds for Study Permit/Visa refusals are subject to a $215.00 administrative fee as well as the $150.00 non-refundable application fee.
Refunds made to credit cards are subject to a 2% service charge. Refunds will be processed only after ASM received and verified all required
documents. Refunds will normally take up to 30 Business days to process once all required documentation is received.

Acsenda School of Management (ASM) collects and uses personal information in accordance with applicable provincial and federal privacy legislation.

Student Signature: Date:

FOR OFFICE USE ONLY:

Received by: Admissions Enrollment Services Name: _______________________ Date: __________________

Student Enrolment Term: _____________ Withdraw term: _____________ Visa Refusal: Yes No

For Visa Rejected, letter of rejection verified: YES NO N/A Verified by: _____________________________

Account Balance: __________________ Fees withheld: ______________ Amount to be refunded: $________________

Authorized by President: ___________________________________ Date: _____________________________________

Processed by Accounts: ___________________________________ Date: _____________________________________

ACSENDA Refund From DFS/FORMS/Students