Studenten Service Centrum

UM SPORT
Postbus 616
6200 MD Maastricht
E: umsports@maastrichtuniversity.nl

REFUND REQUEST
Reason for request:
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Period of refund: ……………………………………….………………………………………………………….…………….
Attention:
 With approval from the review committee of UM SPORTS the amount of money for the refund will be
transferred to your bank account by the department of Finance of the Student Service Centre. If
your request is rejected we will inform you within 4 weeks.
 If required: Include Medical certificate, proof of internship, proof of deregistration study etc.
 With a refund request, €5,- administration fee will be charged.
 Only completed forms can be processed.

Name/initials: ………………………………………………………………………………………………….

Student/Employee ID-number:…………………………………………………………………………………….

Date of Birth: ………………………………………………………………………………………………….

Address: …………………………………………………………………………………………………..

Zip code/City/Country: …………………………………………………………………………………..............

Email address: ……………………………………………………………………………………………………

(Dutch) Bank Account Number: IBAN: ………………………………………………………………………

BIC: ………………………………………………………………………..

City/Town: ……………………………………………………….

Date: ……..………………………………………………..

Signature: