REFUND REQUEST FORM

Enrolment Details

Agent Name:

Student Name:

Date of Birth:

Course Name:

Phone / Email:

Reason for refund: Visa refusal Course Cancelled by Student Provider Default

*** Visa Refusal - You must attach a visa refusal letter from the Department of Immigration

Agents/Student Account Details

Account: Agent account Student account

Account Name:

Account Number:

BSB Number: Swift Code :

Bank Name:

Bank Address:

If you have put agent’s account details instead, a refund authorization letter, signed by the student
agreeing to the claim, must be attached.

Student Signature _______________________________________ Date ______________________

OFFICE USE ONLY:

Amount Student Paid ( to be filled by Marketing Manager) Date Refund Request Received:
Enrolment Fee (Non Refundable) $
Tuition Fee: $
Material Fee: $
Other Fees (OSHC/ Homestay): $
LESS
Agent’s Commission: $
Cancel Administration Fee $
Enrolment Fee (Non Refundable) $
Other Fees: $
AMOUNT TO BE REFUNDED $

Marketing Support Checklist Date Actions Made:

eCOE Cancelled Yes No Initials:
SSO informed by email Yes No Initials:
Accounts Receivable informed by email Yes No Initials:

Refund Authorisation: Approved Due Date: Rejected

PEO Signature Date

Accounts Checklist Date Refund Request Received:

Refund Paid Yes No Initials:
MYOB Updated Yes No Initials:

V3.0 – August 2016 Page 1 of 2 Updated by: KT

Refund Authorization Letter from Student
To whom may concern,

I, _________________________, agree and authorize my sole student agent

representative in Australia, ________________________, to claim my tuition refund fee
on my behalf.
I, _________________________, hereby also warrant that all documents /
identifications given to Queens College from me and my agent are all authentic.

Sincerely,
Signature: ________________________
Student Name: ____________________
Date:

Agent’s Declaration

As above, concerning the authorization of a refund of tuition and on behalf of the

student, I, __________________________, have explained and informed the
student accurately about the refund policy and procedures of Queens College.
Moreover, I will refund said student the correct amount within a reasonable time
once the refund from Queens College has been received.

Agency/Company Name: ________________________________

Authorized Officer Full Name: _____________________________
Signature: ____________________________________________
Date:

V3.0 – August 2016 Page 2 of 2 Updated by: KT