Cancellation / De-registration Form

This cancellation / de-registration form is for FEE liability purpose ONLY. It must be completed in full either by the individual student or staff member within the Adult Education Department. Please note that once assessed the Fees & Grants Office will be requesting confirmation from the Head of the Adult Education Department.

Academic Year *

Student No. *

Student Name *

Address *

Maynooth University Email *

Please note correspondence will be returned to this email address only.

Course *

Date of Requested Cancellation *

Day

Month

Year

Did you attend the course for any period *

Yes

Please tick one box only

If you tick YES above - Please indicate the dates of attendance OR the number of tutorials attended

Date From	Date To	Number of Tutorials Attended
Date From Day Month Year	Date To Day Month Year	Number of Tutorials Attended

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Cancellation / De-registration Form