Refund Request Form

Name

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Phone(Required)

This form is to request a refund. I understand as a general rule, membership fees are not refundable. Exceptions are granted on a case-by-case basis. Approval must be granted by the Assistant Director, Recreational Sports – Membership Services. Warning: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents shall be subject to penalties which may include fines, imprisonment or both, under the U.S. Criminal Code and 20 U.S.C. 1097. To acknowledge enter signature below.(Required)

I acknowledge the above statement

I am submitting a refund for the following product(s):(Required)

Date of product(s) purchased:(Required)

Amount of Original Purchase:(Required)

Order Number:(Required)

Refund Amount Requested:(Required)

Reason for Refund Request:(Required)

I am interested in receiving:(Required)

Please indicate if you are interested in an extension of membership or service to a later semester or if you are requesting a refund back to original payment method used.

CAPTCHA