STUDENT’s FULL NAME: Segundo Gaspar Quispilema Veintimilla Refund Request Form

Choose the method of payment used to pay for the course.

Credit Card Wire-Transfer

Account Holder Name: Account Holder name:

___________________________________________________ Segundo Gaspar Quispilema Veintimilla
________________________________________________________
Credit Card Type: Ambato-Ecuador
Address: ________________________________________________
Visa American Express
Banco del Austro
Name of the Bank: ________________________________________
Mastercard Discover
Other _______________________ 0518040081
Account #: _______________________________________________
Credit Card #: Routing #: _______________________________________________
AUSTECEQ
SWIFT Code: ____________________________________________
Expiration Date: ____/_____ Security Code: ____________
MM YYYY
Check
Invoice # ________________
Account Holder Name:
Credit Card Billing Address:
________________________________________________________
Street: _____________________________________________
Check #: ________________________________________________
City: _______________________________________________

State: _______________________ Zip Code_______________ Cash

Country: ____________________________________________

Telephone: __________________________________________ Online/PayPal

Email: ______________________________________________

REFUND INFORMATION
Request Reason

Segundo Gaspar Quispilema Veintimilla

I, ____________________________________________, am
requesting South Beach Languages for a refund.
Total Refund Requested (Fees are non refundable)

$ 500
Signature Date (MM/DD/YYYY)

01/21/2022

No cash Refunds.If paid by cash, refunds will be made by check. All refunds requested in the form or wiretransfers will incur the associated fee.
F1 Visa applicants who have been denied are required to send us the DENIAL LETTER given by the American Embassy as well as the original I-20 FORM.
Your completion of this authorization form helps us to protect our valued customers from credit card fraud. South Beach Languages will keep all information
entered in this form strictly confidential.

APPROVAL
Director’s Approval Signature Payment Issued by: If Not Approved describe the reason:
APPROVED
___ Credit/Debit Card
NOT APPROVED ___ Check
___ Wire-Transfer
Date (MM/DD/YYYY)
___ Online/PayPal

227 9th Street, Miami Beach, Florida, 33139. Phone: (305) 397.8298 Fax: (305) 397.8251 www.southbeachlanguages.com
Last update: 2.18.2013