Version No.F/ZAF/DHALSP/16 Approved By: Finance

Partnering Governments. Providing Solutions.

LESOTHO SPECIAL PERMIT REQUEST FOR REFUND FORM

• Kindly complete the below details to assist us in processing the refund request

• All fields are mandatory and incomplete information will delay the processing of your refund.

• Ensure that original proof of payment is attached along with this completed request for refund form is submitted • Signature of Applicant and VFS Centre supervisor is required.

• All refunds for cases where the fees was paid via the Prepayment at Bank options will only be paid into a South African Banking Account

• No payments will be done to a credit card number unless it was used for online payment

• A No show/Cancellation penalty of R570 will apply. • All refund requests for online payments must supply beneficiary reference number on payment and Application

reference number(e.g LSP1234567)

Applicant Information Required

Name of applicant Beneficiary Reference number on payment

Application Reference Number eg, LSP1234567

Initial Amount Paid

Date on which Refund Request was submitted

Final Refund Amount Less (R570)

Method of payment Date of Payment

Email ID of applicant Contact Number

Reason for Refund: _____________________________________________________________________

Bank Details: PLEASE CHOOSE ONE

Cash Deposit Refunds Visa/Master card Refunds

Account Holders Name Card Holder Name

Bank Name Branch Code: Card Number

Account Number Expiry Date

Declaration –I hereby acknowledge that my personal and Banking Details are correct and I will be responsible for any delay/incorrect transfer due to incorrect/incomplete information provided by me.

It is important to note that once an appointment has been confirmed, a full refund of the VFS Global’s service fee is not possible, except in the case of h or hospitalization. All cancellations and no shows will attract a fee of 300, which will be deducted from the VFS service fee. No fee will be charged if the applicant is unable to honour the appointment due to his or her death or hospitalisation.

Once an appointment has been confirmed a person can thereafter reschedule an appointment twice. Thereafter if the maximum attempts have exceeded, the VFS Global’s service fee of R300 will be forfeited. Rescheduling or cancellation of confirmed appointment is allowed up to forty eight (48) hours prior to the scheduled date of appointment. Eligible refunds require thirty (30) calendar days processing from the date of refund

request.

_____________ ______________________ _______________________ _________________ _________________

Applicant Supervisor Name/Signature Location/Cost Centre HOD Name/Signature Finance

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Date Date Date Date

For office use only:

N0 ___ /_______________

Payment Processed on (date): ______________ Payment Processed by:________________

VFC Validation Completed________________ Findings______________________________________________________

Finance Validation Completed_________________ Findings__________________________________________________