Cancellation Notification Form-Citizen Ambassador Program

Cancellation Notification Form Form

Citizen Ambassador Program
This is written notification of my cancellation from the delegation listed below.

I understand that if I am cancelling at or within 90 days of the delegation convene date, I am subject to the terms and conditions as agreed upon at the time of my application for the delegation. (See below). If I am eligible for a refund of my deposit or program fees paid (based on cancellation date), I understand that the refund will be issued in 10-14 business days and processed back to the original form of payment.
Delegation Title *
Association Name and Destination
Delegate*

First NameLast Name
Accompanying Guest

First NameLast Name
Email
example@example.com
Written Cancellation Notice Date*

MonthDayYear
Date written cancellation notice was received by Citizen Ambassador Program
Delegation Convene Date*

MonthDayYear
Number of days prior to convene date, written cancellation request received
Cancellation fees are based on the date of the cancellation notice. Cancellation fees, as listed in the terms and conditions of participation, accepted at the time of application are calculated as follows:
- Cancellation notice received greater than 90 days prior to the delegation convening date - full refund of all funds paid
- Cancellation notice received within 90-61 days prior to the delegation convene date - the cancellation fee is 50% of program cost including loss of deposit paid
- Cancellation notice received within 60-31 days prior to delegation convene date - the cancellation fee is 5% of program costs including loss of deposit paid
- Cancellation notice received within 30 days or less prior to delegation convene date - 100% of program costs including loss of deposit paid
If a balance is due based on the cancellation fee calculation, you will be invoiced for the balance or the balance may be chagred to the card on file.
Cancellation Terms and Conditions:

In order to coordinate an exchange of this complexity and based on payments made by the Citizen Ambassador Program to our overseas logistics coordinators on behalf of the delegation, cancellations are subject to a cancellations penalty (listed below) by windows of cancellation. This policy is clearly stated in the Delegate and Guest Terms and Conditions of Participation- accepted at the time of application.
Signature*

Clear
Information below to be completed by Citizen Ambassador Program Staff
Cancellation Penalty

No Penalty: Greater than 90 days prior to convene date - Full refundPenalty: 90-61 days prior to delegation convene date: 50% of program cost or loss of Deposit paid-no refund of the $500 depositPenalty: 60-31 days pror to delegation convene date: 75% of program costs30 days or less prior to delegation convene date: 100% of program costs
Payments recieved USD$
Pull Customer payment record from Stripe
Cancellation Penalty USD$
Minimum $500
Refund Due USD$
Balance after cancellation penalty assessed
Refund request Date

MonthDayYear
Date submitted for processing
Refund request submitted by
Notes
Should be Empty:

Cancellation Notification Form Form

This is written notification of my cancellation from the delegation listed below.

Information below to be completed by Citizen Ambassador Program Staff