Request to defer

an examination Student Services

Date ______________ Campus__________________

1. Personal Details

Student Number _______________ Student Name ____________________________________

Address ______________________________________________________________________

Email _________________________________________ Phone Number___________________

2. Subject(s) relevant to this request Semester __________

Group
Subject Code Subject Name Exam Date
Number

1.

2.

3.

4.

Please answer the following questions

a) Have you previously applied for a deferred exam? Yes/No

b) Reason for request (chose one below)

Medical (please have medical practitioner complete section 3 on the following

page)

Other special circumstance (attach documentation)

Holmes Institute/Holmes Colleges

185 Spring Street, Melbourne, Victoria 3000, Australia
Telephone: +61 3 9662 2055 Facsimile: +61 3 9662 2083
Email: internationaloffice@holmesinstitute.edu.au Website: www.holmesinstitute.edu.au

CRICOS Provider Codes: Holmes Institute Pty Ltd VIC 02639M, NSW 02767C, QLD 02727M; Holmes Commercial Colleges (Melbourne) Ltd VIC 00898G, NSW
01313G, QLD 01646J; Holmes Commercial Colleges (Melbourne) Ltd 00067C; Holmes Colleges Sydney Pty Ltd 00040C; Holmes Colleges Queensland Pty Ltd
01647G; Melsand Pty Ltd T/A Intensive English College 00168J
3. Practitioners Report (this section to be completed by doctor only)

Date ______________

Duration of condition From: ___________ To: ___________

Nature of condition: Please provide a brief description of the students medical

condition and how it will impact their ability to undertake their exam(s). (Statements
such as the student is unfit for study, will not be accepted. Specific details of the
medical diagnosis however are not required)
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Practitioners name and title .................................... Practitioners Stamp

Practitioners provider or registration number .......

Practitioners phone number .

Practitioners signature Date //.

4. Student Declaration

I, . hereby declare that all information given is true and

complete.

I understand that:
The request must be submitted within three working days following the exam for which
deferral is sought.
The outcome of the request will be sent to me by email to my Holmes webmail account.
Submission of the request does NOT guarantee a deferral will be granted.

..
Signature

Office Use Only

1. Program Manager Approval Yes / No Signature __________________ Date _______

2. Documents Attached Yes / No
3. Diary note in BECAS Yes / No
4. Response email sent Yes / No

Holmes Institute/Holmes Colleges

185 Spring Street, Melbourne, Victoria 3000, Australia
Telephone: +61 3 9662 2055 Facsimile: +61 3 9662 2083
Email: internationaloffice@holmesinstitute.edu.au Website: www.holmesinstitute.edu.au

CRICOS Provider Codes: Holmes Institute Pty Ltd VIC 02639M, NSW 02767C, QLD 02727M; Holmes Commercial Colleges (Melbourne) Ltd VIC 00898G, NSW
01313G, QLD 01646J; Holmes Commercial Colleges (Melbourne) Ltd 00067C; Holmes Colleges Sydney Pty Ltd 00040C; Holmes Colleges Queensland Pty Ltd
01647G; Melsand Pty Ltd T/A Intensive English College 00168J