Documentation of Withdrawal/Cancellation – Emergency Medical Services University, LLC

Student Name *

Student ID Number *

Class Section Number: *

Class Start Date: *

– /Class (Total

Withdrawal/Cancellation Information

Withdrawal/Cancellation Date: *

Total Calendar Days in Period of Attendance (Class Calendar Days): *

Days Elapsed at Time of Withdrawal (Days Elapsed) *

Attendance Percentage = Days Elapsed /Class Calendar Days x 100): *

Reason for Withdrawal/Cancellation: *

Exceptions to Refund Reason (e.g. attended more than 60% of class, transfer, financing, etc… See Refund Policy in Catalog):

Refund Calculation (if applicable) / See Refund Policy in Catalog:

Total Amount Paid by Student (Total Paid): *

Non-Refundable Fees (if any): *

Total Institutional Charge for Program (Total Charge): *

Daily Charge (Total Charge / Number of Days Elapsed): *

Amount Owed to Institution (Daily Charge X Days Attended): *

Refundable Amount (Total Paid – Non-Refundable Fees): *

Refund Due to Student (Refundable Amount – Amount Owed): *

Refund Details

Amount Refunded for Tuition: *

Amount Refunded for Other Charges: *

Total Refund Amount: *

Date

Name and Address of Refund Recipient: *

Method of Refund (e.g., check, credit card refund): *

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Phone: (800) 728-0209
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Our Locations: 501 South 48th Street, Suite 105, Tempe, AZ 85281 – 4945 East 29th Street, Tucson, AZ 85711 – 1730 SW Military Drive, Suite 202, San Antonio, TX 78217 – 6910 Miramar Road, Suite 206, San Diego, CA 92121 – 32980 Alvarado-Niles Road, Suite 810, Union City, CA 94587 – 1452 Hughes Road, Suite 360, Grapevine, TX 76051

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