Refund Request of Payment Made to AMSA
Please use this form to request the refund of a payment made to AMSA by a member or vendor. Submit multiple forms if you only have 2 or 3 requests but if you have a bulk submission, please add as much detail as you can to the form and then upload a spreadsheet of the refundees, please include their email addresses.
Name of Refundee
Refundee AMSA ID (if you have it)
Refundee Email Address
This is the email address that is associated with the payment, for example the email they entered when they completed the membership join form.
Type of Refund
Annual Convention (160)
Scholars Programs (125)
Store Product (120)
AMP Purchase (106)
HEART (155 Foundation)
Domestic Medical Dues
International Medical Dues
Please indicate why we are refunding the payment and also if it is a partial refund or a full refund of the original amount paid. Detail any specific account codes if necessary.
Payments made by Credit Card will be refunded back to the card that was used for the payment and will be processed within 5 - 7 business days. We can not refund back to a different card. If the payment was made more then 90 days from the date of the refund request AMSA will need to issue a check to the refundee. If the card used for the original payment is no longer active, AMSA will need to issue a check.
If the original payment was made by cash or check AMSA will need to issue a check to the refundeee. If we need to issue a check, please indicate the address to receive the check below.
Original Form of Payment
Address to Mail Check
If we are doing a refund by check, please put the address to mail the check. Check refunds will be processed within 7 to 10 business days.
Amount of Refund
Requested By (AMSA Staff Person)
Avanthi Jayaweera (email@example.com)
Becky Martin (firstname.lastname@example.org)
Christine Comizio (email@example.com)
Dylan Favre (firstname.lastname@example.org)
Holly Spellmann (email@example.com)
Jamie Thayer Scates (firstname.lastname@example.org)
Jennifer Salehi (email@example.com)
Nabila Fasihi (firstname.lastname@example.org)
Perry Tsai (email@example.com)
Pete Thomson (firstname.lastname@example.org)
Sandy Fridy (email@example.com)
Stephanie Perkowski (firstname.lastname@example.org)
Susan Silva (email@example.com)
Please attach any documentation related to the refund if you have any.
Send me a copy of my responses
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