Student Refund Wire Transfer Form

2750 14th Avenue, Suite 306 Markham ON,
Canada, L3R 0B6
Toll Free: 1.800.832.5104
Fax: [phone]
Email: [e-mail]
Student Information
Student Name
Date (MM/DD/YYYY)
Currency of Wire
Refund Amount
Telephone Number
Email Address
Beneficiary Bank Information
Account Number/IBAN Number
Bank Name
Bank Address
Bank Address 2
City Province/State
Country Postal/Zip code
SWIFT/ABA/ROUTING number
ACH
Beneficiary Details
Beneficiary Name
Beneficiary Street No
Beneficiary Street Name
Beneficiary street Name 2
City Province/State
Country Postal/Zip code
Intermediary beneficiary bank*
*IF YOUR WIRE TRANSFER MENTIONS DETAILS OF AN
INTERMEDIARY BANK, PROVIDE THEM IN THIS SECTION.
Account Number/IBAN Number
Bank Name
Bank Address
Bank Address 2
City Province/State
Country Postal/Zip code
SWIFT/ABA/ROUTING number
ACH
STUDENT REFUND: WIRE TRANSFER INSTRUCTION FORM
PLEASE ENSURE THAT ALL SECTIONS ARE COMPLETED IN FULL. ANY CHANGE IN INSTRUCTIONS MUST BE
PROVIDED IN WRITING TO PAYMYTUITION PRIOR TO THE TRANSFER.
\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\
SYLVESTRE JUNIOR ONKA LIBOKO
ONKA TSOUH RODHE PROFINA
20/12/2001
120
XAF
MPITA
2000$CAD
[phone]
POINTE NOIRE
POINTE NOIRE
[email protected]
CONGO
661
CG39 3001 02000 37207310848 39
Banque Commerciale Internationale Groupe BCP
AGENCE POINTE NOIRE
POINTE NOIRE
POINTE NOIRE
CONGO
BCBPCGCGXXX