APPLICATION FOR WITHDRAWAL OF STUDY

(Not applicable to Research programmes and PolyU award programmes administered by SPEED)

Please read the notes overleaf before completing this form.

I.PARTICULARS OF STUDENT

Name / Student No.

ProgrammeStream

Programme Title / _

Department Mode of Study *FT/PTE/SAND/PT/MIX/DL

Address

Day-time Contact Number: / Email Address:

# Are you a non-local student requiring student visa/permit to stay in Hong Kong?*Yes/No

II.APPLICATION DETAILS

I wish to discontinue my study at PolyU with effect from Semester of the / academic year due to the following reason:-

(please choose the main reason and  only ONE box below and provide the required information)

A3 / Admission to programme of an overseas institution (not including emigration)
Name ofInstitution:
______
Country: ______
Programme Title :
______
(*ResearchPostgraduate/Taught Postgraduate/ Undergraduate/Sub-degree)
A4 / Unsatisfactory academic results
A5 / Heavy academic workload
A6 / Other academic reasons (please specify)
______
N1 / Employment / Job related reasons
N2 / Overseas business duties
N3 / Health & medical reasons(of the student himself/herself)
N4 / Financial reason
N5 / Emigration
N6 / Adaptation & adjustment reasons
N7 / Other non-academic reasons (please specify)
______
A1 / Admission to another PolyU programme
Programme Title :
______
(*Research Postgraduate/Taught Postgraduate/ Undergraduate/Sub-degree)
(*UGC-funded/Self-financed/Not applicable)
Have you retaken the HKDSE/other exam in the case of admission to undergraduate/sub-degree programmes? *Yes/No
A2 / Admission to programme of anotherlocal university/post secondary institution
Name of Institution:
______
Programme Title :
______
(*Research Postgraduate/Taught Postgraduate/ Undergraduate/Sub-degree)
(*UGC-funded/Self-financed/Not applicable)
Have you retaken the HKDSE/other exam in the case of admission to undergraduate/sub-degree programmes? *Yes/No
*delete as appropriate
  1. DECLARATION

(a)I agree to settle/clear all outstanding fees/fines/loans with the Department, Library, Finance Office and Centre STARS should there be any.

(b)My student identity card *is/is not attached.

(c)Applicable only to students who have not returned the student identity carddue to loss of card

I,______hereby declare that my student identity card has been lost. I undertake to return the card to the Academic Secretariat of The Hong Kong Polytechnic University should it be found subsequently. I fully understand that making a false declaration is a criminal offence and may result in the University’s reporting the case to the Police.

Signature of Student Date

#PolyU will inform the Immigration Department once it is confirmed that you have withdrawn from your study. According to immigration regulations, you must leave Hong Kong within 4 weeks after withdrawal approval from the programme.

*delete as appropriate

______

FOR OFFICE USE

DECISION OF FACULTY OFFICE/SD/SHTM

Application received on with Student ID Card *attached/not attached.

Withdrawal application input in system by ______on .

Withdrawal *approval/disapprovalupdated in system by ______on .

*Approval/disapproval letter sent to student by ______on .

Student ID card cancelled by on .

*delete as appropriate

(31 Jul 2015)

NOTES TO STUDENTS

  1. Application for withdrawal of study for the current semester must be submitted before the commencement of PolyU’s scheduled examination period. Application submitted after the commencement of the examination period will not be processed. For application of withdrawal of study for the following academic year/semester, application should be submitted before the commencement of that academic year/semester.
  1. Please clear the following outstanding matters,where applicable, before submission of the form:-

(a)Clear all outstanding matters with your Department.

(b)Clear/settle all outstanding loans/fines with the Library.

(c)Settle all outstanding tuition and/or other fees with the Finance Office.

(d)Settle all outstanding Hall fees with the Centre STARS.

(e)Clear your locker, remove the padlock and leave the door of your locker open, and report to the Centre STARS (Room S203) immediately.

(f)Repay PolyU administered scholarships and/or bursaries/loans to the Centre STARS.

  1. Please return the completed application form together with the PolyU student identity card to your Faculty Office/School of Design (SD)/School of Hotel & Tourism Management (SHTM). For the field of mode of study, please note that FT=full-time; PTE=part-time evening; SAND=sandwich; PT=part-time; MIX=mixed-mode; and DL=distance learning. If you have lost your student identity card, you must make a declaration in Section III and undertake to return the student identity card to the University should it be found subsequently. The Faculty Office/SD/SHTM shall give you a reply within 21 days upon submission of the application. Please note that this form is not applicable to Research programmes and PolyU award programmes administered by SPEED. Please visit the website of Research Office ( or SPEED ( for details of the application procedures.
  1. All fees paid are non-refundable. However, for new students enrolled on UGC-funded programmes who apply for withdrawal of study before the commencement of their 1st semester and have paid the tuition fee for that semester will be eligible for a refund of the tuition fee paid after deducting a fee of HK$5,000 (for local students) and HK$15,000 (for non-local students). If the tuition fee paid is equal to or less than the above amount, no refund will be arranged. The deduction of such fee will however be waived for current students. For applications submitted after the commencement of a semester,all students are required to settle all outstanding tuition fee and/or other fees before such applications will be processed. For the caution money you paid at your first registration, PolyU will send the refund to you after your application has been approved.

5.The information given in the form will only be used for processing this application.