GOG Refund Request Form

Mail the completed form via intracampus mail to:

Kuldeepsinh Rana
Georgen Hall, 232
King Lab, Biomedical Engineering
Rochester, NY 14627-0166

Name:

Student ID:

Department:

Year and status (e.g. 2nd year, full time):

E-mail address:

Please summarize the reasons for your request as specifically as possible:







What would you like to see the Graduate Organizing Group do differently? Is there anything that would make you reconsider your refund request?







I, by signing below, agree not to participate in any GOG-sponsored events nor intentionally benefit from any services by GOG during the effective duration of this refund.

Signature:

Date: