Customer Refund form

Customer Refund form Please fill in the form below and email it to Orygen Finance at [email protected] To view out Refund Policy visit https://orygen.org.au/Footer‐Page/Refund‐Policy Customer Name Customer Contact Details Refund Payment Method Credit Card – Please note refunds to credit cards will only be made to the purchasing credit card EFT – Please provide bank details below Bank Account Details Account Name: BSB: Account Number: Item The resource, workshop or event for which you are applying for a refund Date The scheduled date of the workshop or event for which you are applying for a refund or the date of purchase if your application relates to a resource Basis of your refund request: Please select yes or no below. If you circle yes, please attach evidence of problem or fault*. The resource I purchased has a problem or fault. Yes No I cancelled and notified Orygen in writing 28 days or more before the date of the workshop or event. Yes No I cancelled and notified Orygen in writing less than 28 days but more than 7 days before the date of the workshop or event. Yes No For cancellations notified to Orygen in writing 7 days or less before the date of the workshop or event, no refund will be paid. The workshop or event was cancelled by Orygen. Yes No Amount Paid Date Paid I have attached evidence of payment Yes No * Signature & Date ______________________________ By signing, I warrant that the information provided in this application is true, complete and correct. DD/MM/YY *Please note that applications without supporting evidence may not be eligible for a refund. For Office Use Only Reference Date Received Due date for decision notification Recommended Refund Amount Notes Approval Amount: $ Signature: ________________________________ DD/MM/YY Position Title: Approver’s Financial Delegation for Refunds $2,000 $5,000 Over $5,000 Refund Amount Item Code Account Number Date of decision notification Date of payment Confirmation of payment 2