APPLICATION FORM FOR TUITION FEE REFUND 
Please complete this form and return to Student Records Office, Academic Registry.
Note: Failure to supply all the information requested may result in delay to any payment.

Section A – Student Details

Name:
	
Bangor Student ID Number: 500_ _ _ _ _ _	
Course:	Academic Year (e.g. 2011/12):	
Contact e-mail address for correspondence: 	

Section B - Account details from where payment was made (if cash payment go to section C)
Refunds will normally only be made to the bank (or other financial institution) and account holder that originally paid the fee	
Name of Payee: (Account Holder)		
Sort Code: (Electronic Transfers only)
IBAN number:(Overseas accounts only)		
Bank Account Number: (Electronic Transfer only)		
Amount of Payment:(*)		
	
Section C -  If the payment was made in cash
	
Which payment method do you require?                 BACS                   Cheque

If BACS, please complete section D below, if Cheque, please provide address details below:

Address for cheque or remittance notice (must be completed) to be sent to:
	
Section D – Account details to where the BACS payment should be made	
Name of Payee: (Account Holder)
		
Sort Code: 
IBAN number:(Overseas accounts only)		
Bank Account Number: 

Section E – Confirmation
	
I hereby request that any tuition fee refund due to me is paid in accordance with the above instructions.                                                       	
Signed:
	Date:	

The amount refunded will be in accordance with the University’s ‘Tuition Fee Refund Policy’ (as amended)
http://www.bangor.ac.uk/ar/main/fees/other1112.php.en  

Academic Registry Use Only:
	
Amount to be
refunded £
	Prepared by: 
(Signature)	Authorised by  (AR) 
(Signature)	Date:	
Reason for approval / non approval of refund:

	
			                   
Finance Office Only:  	
Notice of Costs for the above transaction 	g98005k05