DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE
Special form is available for medical absences or withdrawals requiring certification by attending physician.

Tuition Refund Plan
DISMISSAL OR WITHDRAWAL CERTIFICATE

To be completed by the parent or guardian
   Date: Select Date
 
I HEREBY CERTIFY to A.W.G. DEWAR, INC. that has severed his/her
 (Student's name) 
connection with  School/College as of Select Date.
(DATE)
 
I hereby certify that this student has attended every full class day scheduled during the first fourteen consecutive calendar day period from his/her first class day.   YES    NO
 
Reason(s) for withdrawal or dismissal:
 
I hereby authorize A.W.G. Dewar, Inc. to make settlement payable to the above School/College, such settlement to be credited to my account, with any excess to be remitted to me through the School/College.
 
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
 
Parent or
Legal Guardian or
Person Financially Responsible


                                                         (SIGNATURE)
Address   

Telephone #  
 
Note:  This form must be returned to the School/College for transmittal to A.W.G. DEWAR, INC. as soon as possible, in any event, not later than 30 days after date of withdrawal or dismissal.
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