REFUND FORM
Date
6/8/2023
: ____________________________________________________________________
I, the undersigned below :
!
Name of Parent
Dolly Susanto
: ____________________________________________________
Home Phone Number
:
Mobile Number
: ____________________________________________________
08999933308
E-mail
:
08999933308
____________________________________________________
dollysusantoid@gmail.com
____________________________________________________
would like to request for refund :
!
Event
: ____________________________________________________
Amount
5.000.000
: IDR _______________________________________________
For my child
:
!
Name of Student
: ____________________________________________________
Matthew Rei Effendy
Class
: Preschool ___________________ / Primary ________________
Secondary____________________ / JC ___________________
Below are the details for my account number :
Bank
:
BCA
____________________________________________________
Account Name
:
Dolly Susanto
____________________________________________________
Account Number
:
____________________________________________________
Yours sincerely,
Acknowledged by,
Approved by,
_________________________
Parent’s Name and Signature
_________________
Administration Officer
___________________
Head of Administration
*) Please attach the copy of your ID Card & Family Card together with this form.