Refund Request Form

Refund Request Form
Section 1 – Student Details
Name: *
Student ID *
Date of Birth

Day Month Year
Date
Email: *
example@example.com
Mobile: *
Address: *
Course *
Course Start Date:

Day Month Year
Date
Section 2 – Refund Details
I request a refund for the following:
Amount: *
Please tick the type of Refund: *

Withdrawal Transfer Cancellation Visa Refusal Other (Please specify)
Reason: (Please attach any supporting documentation) *
Support documentation upload

Cancel of
Refund Method

Onshore Transfer
Account Name
BSB
Account No.
Overseas Transfer (Transfer fees applies) fill all details below to avoid delays.
Country
Beneficiary Name
Beneficiary Address
Bank Name
SWIFT CODE
Bank Address
Account Number
IFSC CODE/ Branch Number (if applicable)
Acknowledgement *

I understand that my request for a refund will be processed in accordance with Refund Policy. Signing this form does not mean that it is approved, you need to wait for Glen Institute's approval communication.
Signature *

Clear
Date: *

Day Month Year
Date
Section 3 - Account Authorisation (Office Use Only)
This refund amount is:

Approved Denied Adjusted to $
Comments / Reason for decision / Calculations of Refund:
Signature

Clear
Position:
Print Name:
Date Processed:

Day Month Year
Date
Admin Use Only
Logged in Refund Register: Yes No Date Date
Logged by: Signature
Formal Letter/Email Sent: Yes No Date Date
Sent by: Signature
SMS Updated: Yes No Date Date
Updated by: Signature
Should be Empty:

Section 3 - Account Authorisation (Office Use Only)