Request for Assignment Extension Support On The Basis of Disability

Please fill in the sections below and note:

- Not filling in complete details may result in a delay in the implementation of this extension. We will endeavour to contact you to confirm arrangements.

- The Disability Services Officer needs time to notify teaching staff. If you are applying with less than 3 days before your assignment is due, please make an appointment to see the Disability Services Officer.

Full Name *

SID *

Phone 1 *

Phone 2 

E-mail *

Subject Name *

Subject Code *

Assignment Due Date *

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  / 
day

January February March April May June July August September October November December
month

year

Lecturer or Unit of Study Coordinator *

Please give the extended time you would like to request to complete this assignment and brief reasons of why you require this extension: *