Form AS 6
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.
Programme
Stream
_
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
academic year due to the following reason:-
of the
/
(please choose the main reason and  only ONE box below and provide the required information)
A1
Admission to another PolyU programme
A3
______________________________________
Country: ______________________________
(*Research Postgraduate/Taught Postgraduate/
Undergraduate/Sub-degree)
(*UGC-funded/Self-financed/Not applicable)
Programme Title :
_______________________________________
Have you retaken the HKDSE/other exam in the
case of admission to undergraduate/sub-degree
programmes?
*Yes/No
Admission to programme of another local
university/post secondary institution
overseas
Name of Institution:
______________________________________
Programme Title :
A2
Admission to programme of an
institution (not including emigration)
(*Research Postgraduate/Taught Postgraduate/
Undergraduate/Sub-degree)
A4
Unsatisfactory academic results
A5
Heavy academic workload
A6
Other academic reasons (please specify)
_______________________________________
N1
Employment / Job related reasons
(*Research Postgraduate/Taught Postgraduate/
Undergraduate/Sub-degree)
(*UGC-funded/Self-financed/Not applicable)
N2
Overseas business duties
N3
Health & medical reasons (of the student
himself/herself)
Have you retaken the HKDSE/other exam in the
case of admission to undergraduate/sub-degree
programmes?
*Yes/No
N4
Financial reason
N5
Emigration
N6
Adaptation & adjustment reasons
N7
Other non-academic reasons (please specify)
_______________________________________
Name of Institution:
______________________________________
Programme Title :
______________________________________
* delete as appropriate
III. 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 card due 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/disapproval updated in system by ___________________________ on
.
*Approval/ disapproval letter sent to student by ___________________________________ on
.
Student ID card cancelled by
.
*delete as appropriate
(31 Jul 2015)
on
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.
2. Please clear the following outstanding matters, where applicable, before submission of the form:(a)
(b)
(c)
(d)
(e)
(f)
Clear all outstanding matters with your Department.
Clear/settle all outstanding loans/fines with the Library.
Settle all outstanding tuition and/or other fees with the Finance Office.
Settle all outstanding Hall fees with the Centre STARS.
Clear your locker, remove the padlock and leave the door of your locker open, and report to the
Centre STARS (Room S203) immediately.
Repay PolyU administered scholarships and/or bursaries/loans to the Centre STARS.
3. 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
(http://www.polyu.edu.hk/ro/) or SPEED (http://www.speed-polyu.edu.hk/) for details of the
application procedures.
4. 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.