Norwich University of the Arts Vice-Chancellor: Professor John Last
Please refer to the guidance on the intranet about intermission before completing this form
APPLICATION FOR INTERMISSION FROM STUDIES THIS SECTION TO BE COMPLETED BY STUDENT. 1. Full Name
2. Student Number
3. Address for correspondence
4. Course title
5. Year of study
6. Please provide details below (continue on the second page if necessary) of why you wish to intermit from your studies. You are required to submit documentation in support of your application in order to confirm the details provided.
7. The University advises students to discuss intermission with a tutor and/or the Academic Support Office. Please indicate who you have discussed this with.
8. Do you have any incomplete units? (Please list)
9. Proposed dates of intermission: Start of intermission: Return from intermission:
10. I confirm that the information I have provided on this form is correct and I agree to the University holding this information for the purposes of processing this application and in accordance with the University’s notification under the 1998 Data Protection Act. I confirm that I have discussed the potential financial implications of taking intermission with a member of staff in the Academic Support Office, and agree to pay any tuition fees or charges for which I become personally liable. I understand that even if I do not return from intermission I will still be liable for any outstanding fees relating to the current year. We will accept a typed or electronic signature only if you email this form to us from your University email account. If you are submitting this form as hard copy, please sign in pen in the space below.
Signed
Date WHEN COMPLETED PLEASE SEND THIS FORM TO THE ADDRESS BELOW:
Academic Registry Tel: ++ 44 (0)1603 610561 Norwich University of the Arts Fax: ++ 44 (0)1603 615728 Room 5, Francis House Email: registry@nua.ac.uk 3-5 Redwell Street Norwich NR2 4SN You will receive a response to your application within 7 days of receipt of the completed form PLEASE DO NOT SEND THIS FORM DIRECTLY TO THE COURSE Office Use Date received
Intermission on health grounds
Documentary evidence
Yes / No
If no, date of further request
Outstanding Units
Yes / No
If yes, which units
Agreed Last date of Attendance:
Yes / No
Agreed return date
Any condition(s) of return (eg medical note, completion of assessment requirements)
Signed:
Assistant Registrar: Academic Support
Signed:
Pro Vice-Chancellor (Student Experience) (final year/postgraduate only)
Date: Date: