Fillable 651 FM A- Student Refund Application (Australian Correspondence Schools)

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651 FM A- Student Refund Application (Australian Correspondence Schools)

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Student Refund Application
NOTE: All refunds are subject to the terms and conditions outlined in the TAFE Queensland Domestic Student Refund Policy and International Student Refund Policy, as presented to students through the TAFE
Queensland Student Rules and Policies. Lodging a refund application does not automatically imply that a refund will be granted. Each refund application will be individually assessed for eligibility. An Administration Fee will
be applied as outlined in the TAFE Queensland Student Rules and Policies.
STUDENT DETAILS
Student number: Family Name: Given Name/s: Student: Domestic
International
Email address: Phone: Mobile:
Postal address: State /Country: Post Code:
REASON FOR REFUND REQUEST
(** Documentary evidence must be attached).
Domestic Students
1.
Student Withdrawal Prior to Start of Study Date (or on or before the Census Date for FEE-HELP or VET Student Loans eligible students)
2. Student Withdrawal On or After Start of Study Date (or after the Census Date for FEE-HELP or VET Student Loans eligible students)
Select reason below:
2 (a) Student choice (User Choice funded students only)
2 (b) Units cancelled by employer (User Choice funded students only)
2 (c) Credit transfer approved (only applies if credit transfer request was submitted prior to the start of study date)
2 (d) Medical circumstances **(supported by doctor’s statement)
2 (e) Family circumstances ** (supported by a statement from a TAFE Queensland counsellor or Director of Faculty, or equivalent)
2 (f) Employment Related Circumstances ** (supported by employer’s statement)
2 (g) Course Related Circumstances ** (supported by a statement from a TAFE Queensland Director of Faculty, or equivalent)
2 (h) Accepted a place offered through QTAC or higher education institution for the current semester ** (supported by evidence of acceptance of offer)
2 (i) Other (please specify)
International Students
Student Withdrawal:
Select reason below:
1 (a) Student choice (only applies for withdrawals prior to course commencement date)
1 (b) Visa rejection
1 (c) Credit transfer approved (only applies if credit transfer request was submitted prior to course commencement date)
1 (d) Withdrawal by TAFE Queensland due to incorrect or incomplete information supplied by student
1 (e) Withdrawal by TAFE Queensland due to failure to meet English language or entry requirements for next course of study (however no breach of written agreement)
1 (f) Medical circumstances ** (supported by doctor’s statement)
1 (g) Family circumstances ** (supported by a statement from a TAFE Queensland counsellor or Director of Faculty, or equivalent)
1 (h) Course Related Circumstances ** (supported by a statement from a TAFE Queensland Director of Faculty, or equivalent)
1 (i) Other (please specify)
THIRD PARTY DETAILS
(This section must be completed if the refund is to be paid to a Third Party. Third Party refunds MUST be signed by the student where no official Third Party Contract exists)
Organisation Individual
ABN / Date of Birth:
Name:
Email address: Phone: Mobile:
State /Country:
Post Code:
DOMESTIC STUDENTS ONLY
(If approved, provide details on how the refund is to be issued).
Refund payable to: State: Post Code:
Direct bank account deposit: Account Holder/s: BSB: Account number:
INTERNATIONAL STUDENTS ONLY
(If approved, all refunds to be deposited into nominated bank account).
Refund payable to: Beneficiary Account Name: BSB: Account number:
Country:
Bank Name:
1 FM 651 A v 3.1 (12/12/19)
© TAFE Queensland. Uncontrolled copy if printed.
Student Refund Application
Bank Address:
Overseas bank account SWIFT code: IFSC code (India only): IBAN Number (For EU Countries):
INTERMEDIARY BANK Yes No
Intermediary Bank Name: Intermediary Bank SWIFT Code (Routing Number/BIC Number):
Intermediary Account Number:
Country:
ACKNOWLEDGEMENT
I certify that the information on this form is correct and complete Student TAFE Queensland Staff
(Domestic only)
Student Signature: Date: / /
Parent/Guardian Name and Signature
(If student is younger than eighteen (18) years of age and is in the care and control of a parent or guardian)
Name(Please print):
Contact phone no:
Signature: Date: / /
Confidentiality and Disclosure of Personal Information: TAFE Queensland complies with the Right to Information Act 2009, Information Privacy Act 2009 and the QLD Public Records Act 2002. We will not make public, disclose or use for purposes
other than those required to provide the services requested, the personal information of the customer except to the extent necessary to comply with any government policy relating to the public disclosure of confidential information (which policy is in place
at the time of reading this document), the customer provides written consent or we are required to by law or Court order.
2 FM 651 A v 3.1 (12/12/19)
© TAFE Queensland. Uncontrolled copy if printed.
Student Refund Application
OFFICE USE ONLY
Refund recommended: Yes No
If no, reason:
REFUND AUTHORISED BY FINANCIAL DELEGATE:
Approved: Yes No
If no, reason:
Pro-rata refund amount approved: $
Name:
Position Title:
Signature:
Name of submitting Officer: Date: / /
Position: Signature:
Change of enrolment processed N/A Yes No
Is the Admin fee to be applied Yes No
NON-APPROVAL SENT TO STUDENT: Yes
No Date: / /
ACTIONS COMPLETED BY INTERNATIONAL:
Name:
Date: / /
Added to International Refund database
Account Balance/Pro-Rata Refund Approved: $
Less Administration Fee (if applicable): $
Total refund to be paid:
$
REFUND PROCESSED BY (Finance Officer):
Name: Refund No:
Signature: Date: / /
3
FM 651 A v 3.1 (12/12/19)
© TAFE Queensland. Uncontrolled copy if printed.
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651 FM A- Student Refund Application (Australian Correspondence Schools)

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Completed 3 September 2020

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