deposit refund form

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Application Form
Deposit refund – SEA Housing
Date of Application:
Surname:
First name(s):
Debitnr:
Address of rented accommodation:
Rental period: from
until
 Name of Accountholder + address
Name
 Bank information of Accountholder
Bank account number
Initials
Full IBAN code
Address
BIC / SWIFT code 1)
Postcode
ABA routing number 1)
City
BRANCH/BANK code 2)
Country
Name of the Bank
Your e-mail address
Address of Bank
Post code
City
1)
For USA: BIC / SWIFT code and ABA routing
number are necessary
2)
Countries without an IBAN code (such as
USA, Canada and Asia) sometimes use a
BRANCH code.
Extra space for specific bank information:
Administratie:
Office use only:
Amount to be refunded: *
Recalculation if applicable: *
*Edited only by Boerhaave Foundation
Ons Doel
Rijnsburgersingel 60
Postbus 569
2300 AN Leiden
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