UTS:INSEARCH Student ID Number

INS0006

Application for fee deferral

Student details
Family Name:
Given Names:
Date of birth (DD/MM/YYYY):
Unit No:

Street No:

Street Name:
Suburb: Postcode:
Telephone: Mobile:
E-mail:

Instalment plan
I request additional time to pay my tuition fees as detailed below.

Current credit:

For the semester commencing:

Amount of fees now due:

I will pay the above fees by the following date(s):

Amount: $

Date(DD/MM/YYYY):

(2nd Instalment if required)

Amount: $

Date(DD/MM/YYYY):

(3rd Instalment if required)

Amount: $

Date(DD/MM/YYYY):

Reason for request:

Funds will be remitted by:

Student Signature: Date (DD/MM/YYYY):

INS0006
(Page 1 of 2)

Name and address of Parents or next of kin

Family Name:
Given Names:
Relationship to student:
Unit No:

Street No:

Street Name:
Suburb: Postcode:
Telephone: Mobile:
E-mail:

Name and contact details of person known to student who does not live with them
Family Name:
Given Names:
Unit No:

Street No:

Street Name:
Suburb: Postcode:
Telephone: Mobile:
E-mail:
Note: you must bring this form when enrolling and paying fees.
The above fees must be paid at the INSEARCH student centre.

OFFICE USE ONLY

Request approved

Revised

Recieved Date (DD/MM/YYYY):

Initials:

Denied

Date (DD/MM/YYYY):

INSEARCH Limited is a controlled entity of the University of Technology, Sydney (UTS).

INSEARCH Limited is a registered non self accrediting higher education institution and a pathway provider to UTS.
INSEARCH CRICOS provider code: 00859D, UTS CRICOS provider code: 00099F
Version July 2014 1405_0714

INS0006
(Page 2 of 2)