Application For Refund Of Fees

Fields with * are required.

APPLICANT INFORMATION *Last Name *First Name *Campus ID#

Note: If you paid by check your check refund will be mailed to the Mailing Address that is on file with the University. You paid by Credit Card, the Credit Card that was originally charged will be refunded.

I hereby request a refund of fees as indicated below, less any amounts not refundable by State and University regulations.

*THE REFUND REQUEST IS FOR Tuition and Mandatory Fees
Application for Admission Fee
Parking
Transcripts, Testing
Other
If other is selected, indicate reason for refund

If Refund Request is for Tuition and Mandatory Fees, or Application Fees, the Term and Year are required.

Term Year

Parking Permit Number (Attach Parking Permit#)
Received by

Signature

*REASON FOR REQUESTING A REFUND Withdrawal from the University
Reduction of Units
Fee Collected in Error
Other
If reason for requesting refund is not due to withdrawal or reduction of units, indicate reason for request.

Your refund will be processed within four weeks after receipt of the request. All refunds are subject to a $10.00 refund processing fee.

Student Signature Date

Received by Date

Please mail form to Student Account Service BH-155, 1250 Bellflower Blvd, Long Beach, CA 90840, fax to 985-8282, or submit at the Cashier's Office BH-148.

(FOR DEPARTMENT USE ONLY)

Authorized Signature Authorization Date

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