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Section 1. Candidate’s details

Candidate name:
Address in full:
University where registered previously:
Previous supervisor:
Dates of previous registration:
Section 2. Candidate’s declaration
I do solemnly and sincerely declare that: I have withdrawn from doctoral registration at ………………………………………………………………………………………………………………… The nature and extent of the research I have completed towards a doctorate at my previous university is as follows: ……………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………… The supervision I received for my doctoral studies at my previous university was as follows: (please indicate whether there are any IP issues that need to be resolved) ……………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………… I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Oaths and Declarations Act 1957. Signed …………………………………………………………………………………………………………………… DECLARED at ………………………………………………………………………………………………………… On …………………………… day of ……………………………………………………………………………… month ………………………………… year Before me ……………………………………………………………………………………………………………… Signed …………………………………………………………………………………………………………………… (Justice of the Peace or Solicitor of High Court)

Approved by Board of Graduate Studies November 2013 Page of