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 |
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I HEREBY CERTIFY to A.W.G. DEWAR, INC. that
has severed his/her connection with
School/College as of
for reasons as outlined below:
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| 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. |
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| 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. |
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| 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. |
| G41603-2 |