Application for Refund Request Form 1020

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PRINTED IN B.C.
4500148178
Please refer to our website or contact a Regional Office to locate the BC Safety Authority office nearest you. Coquitlam 604-927-2041 fax 604-927-2047 Kamploops 250-314-6000 fax 250-377-4406 Kelowna 250-861-7313 fax 250-861-7349 Langley 604-539-3573 fax 604-539-3570 Nanaimo 250-716-5200 fax 250-716-5212 Prince George 250-614-9972 fax 250-614-9949 Victoria 250-952-4444 fax 250-952-4458 New Westminster 505 - 6th Street, Suite 200, New Westminster, BC, V3L 0E1 www.safetyauthority.ca Local Phone: 778-396-2000 fax 778-396-2174 Toll Free: 1-866-566-SAFE (7233) fax 1-888-660-3508
00001
APPLICATION FOR REFUND REQUEST
Note: This application form is used to request a refund of the cost of purchasing a document or permit issued by the BC Safety Authority offices. The information provided will determine whether the refund is allowed under the Safety Standards Act. The issuing office or the Safety Officer will clarify this with the applicant. Processing of the application is approximately 4 weeks after approval has been granted. Original documentation MUST be attached to the refund request. All refunds are subject to a processing fee at the current rate plus the GST. This form is collected to administer the provisions of the BC Safety Standards Act. If you have any questions about the collection, use, or disclosure of this information, contact the Records, Information & Privacy Analyst for the BC Safety Authority at telephone 1-866-566-SAFE (7233).
1.
TO BE COMPLETED BY APPLICANT Reason for request:
Document/Permit number: Applicant name
(please print):
Business Contact Information Address: City: Applicant signature: Province: Postal code: Date:
When this section has been completed, please return form to the BC Safety Authority office or Safety Officer who issued the permit or document for section 2 completion. 2. TO BE COMPLETED BY ISSUING OFFICE/SAFETY OFFICER Issued by office in error : Service performed: Amount to be refunded: Yes No
Obtained by customer in error :
If applicable, number of on-site inspections made: Comments:
Completed by Office:
(please print):
YY Branch code: Tran date:
Signature: MM DD Phone number: Amount:
Doc. No./Permit No.: 3. TO BE COMPLETED BY HEAD OFFICE Certified by:
Amount of refund: Remarks: RESP. 3 4 3 4 DIV. 30 90 30 90 DEPT. 30 90 30 90 ACT. 250 950 250 950
TECH. 7 8 3 8
LOC. 000 000 645 000
GL ACCT. 1405 3000 4921 3310
DEBIT
CREDIT
Certified that the amount to be paid is correct, is in accordance with appropr iate statute or other author ity for payment and/or contract and where applicable that the work has been performed, the goods supplied, the ser vices rendered and/or other conditions met.
Spending Authority signature: Please see attached for approval Safety Officer or issuing office will f orward original application to the Finance Depar tment in New Westminster.
FRM-1020-02 (2009-11-17)
ORIGINAL - FINANCE, NEW WESTMINSTER
PINK - OFFICE COPY