Refund Request Form

Refund Request Form

Refund Procedure

All refund requests must be submitted by completing this form. All refunds are made by check within 30-calendar days from the date of submission of this form. The student may pick up the check in person or request the delivery of the check by mail, in which case the applicable mailing fee will apply. POLY uses only a courier company that has a tracking system ensuring delivery.

The refund check will be made payable to the entity or to the person from which the funds originated. If a student is applying through an educational counselor/agency, the refund will be made payable to the agency, unless Poly Languages is instructed by the student’s agency to pay the student directly.

Personal Information

Student Name *

First

Last

Email *

Email

Confirm Email

Phone *

Date of Birth *

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Which center? *

• Poly Languages at Irvine
• Poly Languages at Los Angeles

Please check all that apply. If you are an F-1 student, you must check the center you are currently registered to.

Please select the Refund Types

Please state accurate information on this form so that we may process your refund as soon as possible. If there are any inaccurate information, you must resubmit this form.

Security Deposit

• Security Deposit for Housing

A student may request a refund only after the student has moved out. Additionally, the student must request refund within 30 days after the student has move out.

Date Moved Out *

Host Family Contact Person *

First

Last

Address of Host Family *

Release Letter *

• Did you receive a release letter from the host family?

The student must submit this form along with the release letter from the host family in order to request the security deposit. The school will contact the host family for authenticity of the release letter.

Release Letter from Host Family *

Click or drag a file to this area to upload.

Acceptable file extensions: pdf, jpg, jpeg, jfif, tiff, tif, gif, png, rtf, doc, docx. The file size must be less than 12 megabytes.

The place was well maintained and clean. *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

My overall living experience was a pleasant one. *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

I would recommend the housing. *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Comments about Housing

Tuition Refund

• Tuition Refund

Basis for Refund *

• I understand and agree that any money not paid, discounts or promotions, will be nullified upon receiving a partial or full tuition refund. The tuition refund is solely based on the money received by the school after all other applicable fees owed to the school are deducted. The tuition charge will be based on the standard (full charge) published price. There is a Credit/Debit Card Service fee of 5% on any money paid by credit/debit cards, and the fee will be deducted against the refund amount due to the student.

The Mission Statement of Poly Languages Institute

The mission of Poly Languages Institute is to provide a fulfilling education to serious students and to create a positive learning environment. We are committed to providing excellent education and rendering great student services.

The staff and faculty endeavors to fullfill the Mission Statement. *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

My overall experience with Poly Languages was pleasant. *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

I would recommend Poly Languages. *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Effective Date Cancelling or Withdrawing *

The date that you input cannot be sooner than TODAY. Please note that inputting inaccurate date can delay the refund process.

Message or Discontinuing Reason *

How would you like your refund check delivered? *

• By mail outside the US ($80)
• By mail within the US ($40)
• I will provide my own self-addressed envelope with a stamp and mail it to: Poly Languages Institute, 18818 Teller Ave., Suite 160, Irvine, CA 92612.

Please note that for the first two options, we use a courier company that offers a tracking system to ensure the secure delivery of your refund check.

Mailing Address – International *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

– Select One –AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Mailing Address – US *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Verification Service *

• Verification Service Fee ($1)

Please note that the credit card information you provide will be used to verify the identity of the person requesting a refund. The cardholder’s name must match either the name of the student or the name of the person who paid the tuition, as indicated on the receipt(s). This is a required field to ensure accurate and secure processing of your refund request.

Total Due: *

$0.00

Assisted by (Optional)

State the name of the advisor who assisted you in completing this form.

Stripe Credit Card *

Card

Name on Card

Acknowledgement and Agreement *

• I understand that this refund request will be nullified if I input any inaccurate or false information. I understand that this refund request will be nullified if the cardholder’s name does not match my name or the person who paid tuition in the school records. Furthermore, I acknowledge that I had access to the School Catalog, and I agree to the refund policies and procedures as stated in the catalog.

Phone

Submit