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UNIVERSITI TUNKU ABDUL RAHMAN

APPLICATION FOR REFUND OF CAUTION MONEY
- MALAYSIAN STUDENT-

Faculty General Office

Universiti Tunku Abdul Rahman

For Office Use Only

Date Received:____________
Signature:________________

Section A - To Be Completed By Student

(Please complete application form in BLOCK LETTERS throughout except email address.)
Student Name (as per I/C): __________________________________ New I/C No: __________________________
Course of Study: __________________________________________ Registration No: _______________________
Email Address: ___________________________________________ Contact Tel No : ________________________
(a) I declare that:
(i) I have * completed / withdrawn from the course and left the University on _____________ (date).
(ii) I am not in arrears of fees.
(iii) I have returned all articles belonging to the University including library books.
(iv) I have settled all other outstanding liabilities (e.g. breakages/loss to laboratory equipment, etc)
(v) I have not claimed any refund of caution money before.
(b) I wish to apply for the refund of my caution money as ticked [ ] below:
Foundation/Bachelor/Master/PhD Programme (RM200.00)

MBBS Programme (RM500.00)

(c) I wish to donate RM _____________ to UTAR Student Loan Fund to help needy students to achieve their goal in
attaining tertiary education.
(d) I wish to authorise the University to refund my caution money through the arrangement that I have ticked ( ) at the
appropriate box provided.
Refund of Caution Money Arrangement:
(i)

Deposit to my Public Bank Account No.:

(ii)

Mail the cheque via ordinary post to my address stated below:

Date: _________________________

Signature : __________________________

Section B - To Be Completed By Faculty

I certify that this student has: (Please tick [ ] whichever is applicable.)
Completed/Withdrawn from the course and left the University.
Caused breakages and damage to the lab equipment
Items
1. _______________________________
2. _______________________________

Replacement Cost (RM)

____________________
____________________

Date: _______________ Staff Name: ___________________________

Authorised Signature: _________________

Section C - To Be Completed By Library

I certify that this student has: (Please tick [ ] whichever is applicable.)
Returned all items
Not returned the following items:
Title
1. _______________________________
2. _______________________________

Author
____________________________
____________________________

Date: _______________ Staff Name: ___________________________

* Delete whichever is not applicable.

Replacement Cost (RM)

_____________________
_____________________

Authorised Signature: _________________