To: JUPAS Office

UG-02 Knowles Building

The University of Hong Kong
Pokfulam
Hong Kong

Request for Refund

I would like to request for a refund being overpayment of my 2011 JUPAS application /
amendment fee via the following channel and for reasons as stated below:
(Please [] as appropriate)

I) Payment Details
Fee Type  Application Fee ($420)  Amendment Fee ($80)
Payment Channel  Credit Card  PPS Online
Transaction details /  E-banking (  HSBC /  Hang Seng Bank /  BEA)
payment slip is/are as per
attached  Cash (  BEA /  JUPAS Office)
Payment Date and Time _____________________________________ Refund Amount HK$____________

 Duplicate payment
Reason(s) for Refund  Incorrect HKID card no. used for payment (HKID card no._______________________)
 Others (please specify) _________________________________________________

II) Personal Particulars of JUPAS Applicant

Name : (Mr. / Miss / Ms.) HKID Card No. :

Copy of the HKID Card is as per attached

Tel. No. : (H) (M) Application No. (if any) : 11

O III) Personal Particulars of Payee

P (To be completed ONLY IF Payee’s HKID card no. is different from Applicant’s)
T
I Name : (Mr. / Miss / Ms) HKID Card No. :
O Copy of the HKID Card is as per attached
N
Address :
A
L Tel. No. : (H) (M)

IV) Declaration
I understand that a refund of application / amendment fee, if approved, will be made to me via one of the following channels, as
appropriate:
Either : i) For payment made via credit card / PPS / e-banking of HSBC / Hang Seng Bank:
To be credited to the original bank account where the payment was made.
Or : ii) For payment made via e-banking of BEA / cash payment at BEA / JUPAS Office:
A crossed cheque will be made payable to the payee and sent to the address as listed above.

Signature of Applicant : Date :

Signature of Payee (if applicable) : Date :

Notes:
 The deadline for application of request for refund is 31 August 2011.
 Refund of Application Fee will be processed after the application deadline, i.e. 2 December 2010.
 Refund of Amendment Fee will be processed after the programme change deadline, i.e. 23 May 2011.

FOR OFFICE USE ONLY

Request received by : Receiving date :

Channel for refund :   Date of completion of refund :

(Please [] as appropriate) Original A/C Cheque
Date of letter sent :