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Exception Request Form

PERSONAL INFORMATION

Student ID *

Identity Verification Birthdate *

Name *

First

Middle

Last

Gender *

Female
Male
Non-Binary

Language preference for communication *

English
French

Preferred Email Address *

Alternate Email Address

Phone number to reach you *

Personal
Business
Both

Personal Phone *

Business Phone *

Address preference *

Home Address
Business Address
Both

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Employer

Business Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

REQUIREMENT DETAILS

I AM REQUESTING AN EXCEPTION FROM CSI POLICY FOR THE FOLLOWING COURSE: (Details available at www.csi.ca)

Course Name *

Exception being requested *

Course Extension
Reduction of waiting period prior to re-enrolment
Other

Exception being requested "Other"

Circumstance *

Medical / Family
Bereavement
Other

Paragraph Text *

Documents to support the need for an exception *

Medical Documentation
Death Certificate
Other

If "other"

Upload Documents *

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

I have attached the following documents to support the need for an exception at this time (Please refer to Requirements & Criteria for exceptions From CSI Policy at www.csi.ca )

DECLARATION AND SIGNATURE OF APPLICANT

Declaration *

I, the undersigned state that the information contained in this request is accurate and permit CSI to verify any information provided in this request.

Signature *

Clear Signature