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Queensland University of Technology

WF

Student Business Services

Victoria Park Road
Kelvin Grove Q 4059
Phone 07 3138 2000 Fax 07 3138 1176
www.student.qut.edu.au
CRICOS No. 00213J ABN 83 791 724 622

1405

Application for Waiver of

Late Fee or Administrative Fee
Instructions - read this before proceeding
This application is associated with the submission of:
Late lodgement of advanced standing ($50.00).
Late lodgement of enrolment ($50.00).
Late additions/substitutions to an enrolment program ($50.00).
Submission of enrolment program not made online ($50.00).
You can lodge this form at any Student Centre counter or mail it to the address above.
For quicker refund processing complete the Electronic Funds Transfer section on page 2 of this form.

1. Personal details
Title (Dr/Mr/Mrs/Ms/Miss etc) .......................................................................................................

Student number

Family name ............................................................................................................................

Given name(s) ........................................................................................................................
Mailing address ......................................................................................................................
........................................................................................................................................................
State ......................................................................................... Postcode

Daytime phone ........................................................................................................................

Mobile ..........................................................................................................................................

Date of birth

day

month year

Course code
Course title ................................................................................................................................
Major ............................................................................................................................................
QUT student email
........................................................................................................................ @student.qut.edu.au

2. Reason for waiver of fee

Type of fee imposed (tick whichever is applicable):

Payment details:

Late application for advanced standing

Receipt number ............................................................................................

Late lodgement of enrolment

Amount paid ....................................................................................................

Late additions/substitutions to an enrolment program

Date paid .........../............/...........

Submission of enrolment program not made online

My reason for application is:

.........................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................

(Please attach any supporting documentation eg medical certificate, letter from employer.)

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Queensland University of Technology

Student Business Services
Victoria Park Road
Kelvin Grove Q 4059
Phone 07 3138 2000 Fax 07 3138 1176
www.student.qut.edu.au
CRICOS No. 00213J ABN 83 791 724 622

WF

1405

Application for Waiver of

Late Fee or Administrative Fee
3. Electronic Funds Transfer details
This information is required to allow direct electronic funds transfer (payment) to your bank account.
The University will treat this with the strictest confidence.
To ensure confidentiality of this information, please enclose the completed form in a sealed envelope
marked Private and Confidential.

Bank details
Account in the name of
Financial institution
Branch name
Bank number (BSB)

(Australian bank accounts only)

Format: xxx-xxx

Account number

Privacy
Details of QUTs practices regarding student information and privacy see www.qut.edu.au/privacy
If you are unable to access the internet, you can contact QUT Student Centre in person, phone 07 3138 2000 or email askqut@qut.edu.au for this
information.

4. Declaration
I declare that to the best of my knowledge the information supplied by me is true, correct and complete in every respect. I acknowledge that the
submission of false, incorrect, incomplete or misleading information may result in cancellation of my enrolment or delays in processing, or that I may
be subject to disciplinary action under the QUT Student Code of Conduct www.mopp.qut.edu.au/E/E_02_01.jsp and the procedures for management
of student misconduct www.mopp.qut.edu.au/E/E_08_01.jsp. I acknowledge that I am subject to and must comply with any policies or procedures of
the University governing my conduct as a student and academic matters affecting my studies.
I acknowledge that it is my responsibility to provide all necessary documentary evidence of qualifications or experience. I authorise QUT to verify
such records through QualSearch or grant my consent for other educational institutions, admissions centres, government bodies or employers to
disclose information about my qualifications and experience directly to QUT.
I also confirm that my bank details, as provided, are correct and I authorise payment to be made to the bank account indicated.

Students signature .................................................................................................................................................................................................................. Date ............/............/............

Student Business Services use only decision

Fee waived:

YES

NO

..........................................................................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................................................................................................

Date received at SBS ............/............/........... Authorised by ........................................................................................................................................... Date entered ............/............/...........

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