REQUEST FOR TUITION FEE REFUND

MAKWANA
1. Last (family) name:................................................ CHANDRIKA KUMARI
2. First (given) name(s):..........................................
BASIC MEDICINE II
3. Program/Year: ……………………..……………. VDNHVU
4. Neptun code: ………………………………….
PAKISTANI
5. Nationality:............................................................. 02/06/2005
6. Date of birth: ......................................................
ckmukwana@gmail.com
7. E-mail: …................................................................ +973 34200126
8. Phone number: ………………………...………
reason:  half-time status/one subject
 overpayment
 tuition fee reduction
 passive semester
 deregistration
 rejected visa
TUITION FEE REFUND
 other: ………………………………………………………………………………………….
Bank details:
BANK OF BAHRAIN AND KUWAIT (BBK)
1. Bank’s name:.....................................................................................................................................................
BUILDING 43, ROAD 303, BLOCK 305
2. Bank’s address:..................................................................................................................................................
3. IBAN number: BH
_ _ - _58_ - BBKU0020
_ _ _ _ _ _ _ _ - _00048283
_ _ _ _ _ _ _ - _63_ _ _ _ _ _ _
OR
Account number: _ 200004828363
_______________________
BBKUBHBMXXX
4. SWIFT/BIC code (8 or 11 digits): .....................................
BAHRAINI DINAR
5. Bank account’s currency:……………………………..
DAYARAM MAKWANA ISAR DAS
6. Bank account’s holder name:............................................................... PAKISTANI
Nationality:......................................
FLAT 63, AVENUE 62, BUILDING 235G, BLOCK 1058, GRAVITY VILLAGE,
7. Address of the Bank account’s holder:...........................................................................................................
ZALLAQ , KINGDOM OF BAHRAIN
8. other information: ……………………………………………………………………………………………
If your bank account is located in countries outside the European Economic Area you should provide the
correspondent/intermediary bank details:
9. Correspondent bank’s name: ........................................................................................................................
10. Account number: ...............................................................
11. SWIFT/BIC code (8 or 11 digits): .....................................
12. ABA/Routing number (9 digits): .....................................

11 ..........................
Date:.......... / 01 /20........
24 Signature:...................................................
Official Use Only!

jelentkezési/vizsgadíj ___________ USD/HUF

visszatérítendő összeg ___________USD/HUF
tandíj I. ________________USD/HUF félév: ______________
- visszatérítés összege __________ USD/HUF
tandíj II. _______________ USD/HUF félév: ______________
- visszatérítés díja _____________ USD/HUF
egyéb: _________________ USD/HUF félév: _____________
Befizetés adatai: