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Refund Application Form by zbq75259

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									FORM 3-E



                                                  Refund Application Form
                                                                           only.
Please complete all the required fields & submit to CASHIER COUNTER 6 OR 7 only. In which student fail to
do so, refund may be delayed.
Student Name        : ___________________________________                 Student ID         :   __________________________
Contact No          : ___________________________________                 Nationality        :   __________________________
Course              : ___________________________________                 E-Mail Address :       __________________________

I wish to request refund for (please tick one box):
          Course Fee Overpayment for Semester _____ Year ______

          Personal Bond

          Others (Please State) ______________________________
(FOR STUDENT HOUSING REFUND, PLEASE FILL UP CHECK OUT CONFIRMATION / CLEARANCE FORM & DEPOSIT
REFUND FORM AVAILABLE AT STUDENT HOUSING)

Reason for requesting refund : ___________________________________________________________________________________

Request mode of payment (please tick one box) :

       Cheque                                   Telegraphic Transfer*                      International Bank Draft*

* Please complete the bank details below. Cost of bank charges shall be borne by the students. Foreign currency T/T and Bankdraft
  shall be translated at the prevailing exchange rate on the day of bank transaction.
       Payee Name
       (Student’s Name as stated :
       in their Own Bank Book )


                                                                          OR
        Please prepare the
        cheque under my           :
       Father’s / Mother’s
       name
       (As stated in their Bank Book )

       Bank Account No            :
       (for T/T & BD only)

       Bank Name                  :      _____________________________________________
       Bank Address               :      _____________________________________________
                                         _____________________________________________
       Bank Swift Code            :      _________________________________________


Signature        : ____________________________
Name             : ____________________________                                     Date          : _______________________

For further enquiries, please contact the Cahier’s Office, Grd. Flr., Building GP 401 at 085-443885 or email finance@curtin.edu.my

Office Use Only :                                                                                   Date Received :
Checklist:
 Items                      Completed                       Remarks
 Student Details             Yes / No                                                               Received By:
 Payment Mode                Yes / No
 Payee Name                  Yes / No
                                                                                                    ----------------------
 Bank Details                Yes / No
                                                                                                    Name:

								
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