First Name

Last Name

Student ID

Gender

Male     Female

Address

Town

State

Postcode

Email Address

Primary Phone

Mobile Phone

Faculty / Department

Key contact person

Summarize in one or two sentences what action, decision or conduct forms the basis of your grievance:

Please give details of your grievance:

Have you completed the grievance procedure with the faculty department? Yes   No

If you answered no to the previous question, please give reasons for contacting the Academic Registrar:

What outcome are you seeking?

Do you give your permission for the Academic Registrar to discuss details of your grievance with appropriate University officers and others outside the University if appropriate? Yes   No

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