NDAEB Withdrawal Request Form

* 1 Withdrawal fees will apply based on the date the NDAEB office receives this withdrawal request! * 2 Applicants withdrawing due to circumstances related to illness or emergency MUST accompany this request with a verifiable physician’s certificate or written verification provided by a religious leader or other professional. NDAEB Withdrawal Request Form Last Name: _________________________________First Name: _________________________________ Date of Birth: _______________________________NDAEB ID / Certificate # : ______________________ To whom it may concern, I, ____________________________________________________________________________________ (Full Name) would like to withdraw my application today 1 _________________________________________________ (date of withdrawal request yyyy/mm/dd) from the (please select one ( ✓ ) ):  NDAEB Written Exam taking place on ____________________________________________________ (WE date yyyy/mm/dd)  NDAEB CPE taking place on ___________________________________________________________ (CPE date yyyy/mm/dd) Reason for Withdrawal 2 : I am withdrawing my application because … _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ I have read the candidate handbook and am aware that withdrawal fees may be assessed and applied based on the date the NDAEB office receives this withdrawal request, and that the NDAEB reserves the right to determine circumstances that qualify as grounds for withdrawal without financial penalty after reviewing and verifying the accompanied documentation in support of an illness or serious personal emergency. As stated in the Reason for Withdrawal section of this form, my withdrawal request is due to an illness/ emergency/ religious circumstance(s). Please find attached to this withdrawal request the following supporting documentation (if applicable):  Physician’s certificate note  Letter from a religious leader  Other (Please specify):________________________________________________________ Signature: _________________________________ Date: ________________ 2283 St. Laurent Blvd, Suite 204, Ottawa, Ontario K1G 5A2 Tel: (613) 526-3424 Fax: (613) 526-5560 Email : [email protected]