Request for Refund

INSTRUCTIONS
1. Please review the Payments and Refund Policy to determine eligibility for refund.
2. Complete this form – this is a fillable form that can be saved and printed.
3. Submit completed form to MLI Homestay via:
• Email at info@mlihomestay.com
• Fax to 416-646-5406
• Mail to MLI Homestay – 415 Yonge Street, Suite 1201 Toronto ON M5B 2E7

4. A representative of MLI Homestay will contact you to discuss your request.

5. Please allow 5-10 business days for processing of the Request for Refund form.

PARTICIPANT INFORMATION
SURNAME GIVEN NAME(S) DATE OF BIRTH (YYYY/MM/DD) NATIONALITY

Iriarte Malfanti Iñigo ______/___/___

2006 12 01 Chilean
PROGRAM LOCATION SCHOOL IN CANADA PROGRAM START (YYYY/MM/DD) PROGRAM END (YYYY/MM/DD)

Burnaby, BC Burnaby South Secondary ______/___/___

2022 08 28 ______/___/___
2023 01 20
REASON FOR REFUND
Cacellation. Change of Provider

REFUND RECIPIENT
REFUND RECIPIENT: ✔ PARTICIPANT AGENT PARENT
NAME OF RECIPIENT TELEPHONE EMAIL
Northwest Homestay and Student Agency 604-628-8491 info@studyabroad.cl
ADDRESS OF RECIPIENT BANK NAME BANK ADDRESS INCLUDING COUNTRY
304 - 8508 Rivergrass Drive Central 1 Credit Union 1900, 13450 - 102 Ave, Surrey
Vancouver BC V5S 0H7 BC V3T 5Y1 Canada
BANK SWIFT CODE

CUCXCATTVAN
ACCOUNT NUMBER BANK NUMBER TRANSIT NUMBER

041000064253 0809 30190

If the wire transfer will be cleared through another bank (a correspondent bank), please complete
CORRESPONDENT BANK NAME CORRESPONDENT BANK ADDRESS

CORRESPONDENT BANK SWIFT CODE

Head Office: 415 Yonge Street, Suite 1201 Toronto ON M5B 2E7, Tel: (416) 646-5405 / Fax: 416-646-5406
North Vancouver Office: 408-197 Forester Street, North Vancouver, BC V7H 2M9, Tel: (604) 904-9488 / Fax: 604-904-9485
info@mlihomestay.com – www.mlihomestay.com