Bearcat Card Refund

Note:

This form works best in Mozilla Firefox and Google Chrome.
VTS Location?

TUCLangsam LibraryCARE/Crawley
Reason for Refund:*

Withdrawing from UniversityGraduating from UniversityEnding employment/University RetirementOther
Amount of Refund Requested (USD)*
UC ID #*
Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email:*
example@example.com
Phone Number:*

Area CodePhone Number
Terms & Conditions
In Agreement?*

I agree to the terms and conditions of the Bearcat CardI do not agree to the terms and conditions of the Bearcat Card
Direct Deposit Requirement?*

I have enrolled in direct deposit.
To learn more about the Refund Direct Deposit Process.
Request Date:*

MonthDayYear
Additional comments?
Balance:
Balance due?
Refund Resolved:

MonthDayYear
Check Bearcat Card Deposit?

NoYes
Trouble Call Placed

MonthDayYear
Date/Time

MonthDayYearHourMinutesAM/PM Option
Upon submission, you will receive a copy of your submission via email.
Should be Empty:

Note: