REFUND REQUEST FORM

Vocational Programs
PLEASE COMPLETE ALL 4 SECTIONS OF THIS FORM IN AND RETURN IT TO: ipdrefunds@lbpsb.qc.ca
PLEASE PRINT CLEARLY IN BLOCK LETTERS - INCOMPLETE FORMS WILL BE RETURNED

1) Student Information:
Student’s Family Name: ______________________________
Date of Birth (mm-dd-yyyy): __________________________
Program Registered: ________________________________
Address: _________________________________________
Street / Civic address
Student’s First Name: ____________________________
Mozaik # (6 digits): ___________________________
Intake date (month-year): ___________________________
______________________________________________
Apartment / Unit

________________________ ________________________ ________________________ ________________________

City Province Country Postal Code

Email Address: ____________________________________________________

Phone Number (mobile): ____________________________ Phone Number (other): ____________________________

2) Refund Information:
Amount Requesting: CAD $____________________

Reason for Refund:

☐ Visa Refused (please include refusal letter)

☐ Overpayment
☐ Other (please specify): _____________________________________________________________________
Refund to:
☐ Student
☐ Other – please fill in the information below and include 3rd party authorization form (page 3)

Full Name: ______________________________________________________________________________

Relation to Student: _______________________________ Phone Number: ________________________________
Email Address: ______________________________________________________________________________
Address: ______________________________________________________________________________
_______________________________________________________________________________

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3) Payment Method:

Payments received by Flywire will be refunded by Flywire back to the original account.
If you did not pay by Flywire, please select one of the following payment methods.
Refund by Credit Card is not available. Please ensure that you complete all required information.

☐ CHEQUE

Cheque will be issued to the student unless otherwise indicated in section 2 (refund information).
If the cheque is to be issued to someone other than the student, please complete page 3 (third party authorization).

☐ DIRECT DEPOSIT (TO A CANADIAN BANK INSTITUTION ONLY)

Name of institution: _____________________________________________________________________________
Bank Phone #: _____________________________________________________________________________
Bank Address: _____________________________________________________________________________
Account #:________________________ Transit #:________________________ Bank #:_______________________

Please include a VOID cheque or bank account

direct deposit information sheet.

If you wish for the direct deposit to be issued to

someone other than the student, please include
the 3rd party authorization form (page 3).

☐ WIRE TRANSFER (TO A BANK INSTITUTION OUTSIDE OF CANADA ONLY)

Name of institution: _____________________________________________________________________________
Bank Phone #: _____________________________________________________________________________
Bank Address: _____________________________________________________________________________

Account #: ___________________________
Transit #: ___________________________
Bank #: ___________________________
Swift Code: ___________________________
ABA (US Only): ___________________________
If you wish for the direct deposit to be issued to
someone other than the student, please include
the 3rd party authorization form (page 3).

4) Signature:
Student’s Signature: ______________________________________ Date: _____________________________
(mm/dd/yyyy)
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 3RD PARTY AUTHORIZATION FORM
Vocational Programs

COMPLETE THIS FORM IF YOU WISH FOR THE REFUND TO BE ISSUED TO SOMEONE OTHER THAN THE STUDENT.
PLEASE PRINT CLEARLY - INCOMPLETE FORMS WILL BE RETURNED.

Student Information:
Student’s Family Name: ______________________________ Student’s First Name: ____________________________
Date of Birth (mm-dd-yyyy): __________________________ Mozaik # (6 digits): ___________________________
Program Registered: ________________________________ Intake date (month-year): ___________________________

Refund To:
Family Name: _______________________________ First Name: ____________________________________

Relationship to student: ____________________________________________________

Email Address: ____________________________________________________

Phone Number: ____________________________________________________

Address: _________________________________________ ______________________________________________

Street / Civic address Apartment / Unit

________________________ ________________________ ________________________ ________________________

City Province Country Postal Code

Signature:
I authorize Lester B Pearson School Board to release my refund to the 3rd party indicated above.
I confirm that the banking information indicated on the refund request form is accurate and that of the third party.

Student’s Signature: ______________________________________ Date: _____________________________

(mm/dd/yyyy)

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