APPLICATION TO ANNUL REGISTRATION DUE TO SERIOUS ILLNESS

PERSONAL INFORMATION

Name: / First surname: / Second surname:
Identity card number (or passport number): / Address for written for correspondence:
Postcode: / Town: / Telephone:
Mobile telephone: / URVemail address:
Student on the course: / Faculty/School: / Universitat
Rovira i Virgili
STUDENT GRANTHOLDER: / YES / NO (annulment of registration also implies annulment of grant application)

I REQUEST:the annulment of my registration due to serious illness

NEW STUDENTS: / YES / NO
If yes, indicate one of the following:
I will collect the documents that I submitted for registration:
I wish to receive the documents that I submitted for registration by post:
* Annulment of registration means that you will lose your place on the course. You will have to go through the pre-registration procedure again if you wish to begin any other course.
I am aware that once my request has been accepted, the Secretary's Office of the Faculty/School will, if necessary, begins the process of returning my registration fees to me.

[place]______, [date] ______

(signature)

DOCUMENTS THAT MUST BE ATTACHED - space reserved for the Secretary's Office of the Faculty/School -

Yes / No
 /  / Official medical certificate (showing the start date of the illness and the period of convalescence).
I am aware that I have a maximum of 10 working days as from the day after presenting this request to provide any documents that are missing. If I do not present the documents within this deadline, the URV will regard my application as withdrawn (art. 68.1 Law 39/2015).

BANK DETAILS:

Please specify the account number that should be debited:

The same account number as when I enrolled (data base) (in this case you need not provide any more details)
My account number is the following:
Client's account code
IBAN / Name of bank / Branch / Control / Account number
SWIFT
Account holder
Identity card/passport number / First surname / Second surname / Name

 I will collect the notification in person from the secretary’s office of the faculty/school.

Mr/Ms, Dean, Director of the Faculty/School - Head of the Secretary's Office

DUTY TO INFORM: The URV is responsible for your data and processes them for the purpose of managing your academic transcript and organising your teaching and study, in compliance with its duty to provide a public service. Your data will only be shared with third parties if the URV is legally obliged to do so or if you subscribe to any of the services provided by third parties that are indicated during this procedure. You have the right to access, rectify, remove, request the transfer, oppose the handling and restrict the processing of your data. You can more detailed information onData Protection on the website of the URV (

Student information
Names and surnames:

Identity card number/passport number:
Address for written correspondence:

Postcode: Town:

Course:

RESOLUCION OFTO ANNUL REGISTRATION DUE TO SERIOUS ILLNESS

Stamp of Faculty/School / Stamp of Faculty/School
The student’s registration will be annulled. / The application is rejected because:
the accrediting documentation (official medical certificate) has not been submitted.
[place] ______, [date] ______
the official medical certificate does not include the required information.
the student is not up to date with payments.
[place] ______, [date] ______
The Head of Secretary’s Office
as delegated by the General Manager / The Head of Secretary’s Office
as delegated by the General Manager

This decision is not the end of the administrative process and, should you wish to do so, you can appeal to the rector of the URV within one month of having been informed of this decision.

STUDENT GRANTHOLDER
Date of reception at SGA: ………………… / REFUND OF REGISTRATION FEES
Date of refund (UXXI): …………………

The student signs this form to demonstrate that he/she has received and understood this resolution.

(signature)......

______[place], ______[date]