Professional Charges Forms

	A Refund has been credited to your bank card for a previously submitted charge as follows: Type of Card: VISA, MasterCard or.Discover
	Date of Charge ___________		_____________________________
			Card Holder Name
	Amount of Charge $_____________

	Total Credit Refund $_____________		_____________________________
			Authorized User, if different
	Refunded by:

	Name ___________________________		_____________________________
			Card Number
	Address _________________________

	________________________________		______________
			Expiration Date
	________________________________

	Phone ___________________		________________________
			Date Refund was Submitted
	Notice:
	This credit refund will appear on your monthly card statement as from ProfessionalCharges.com,or some abbreviation of it, and not the name of your provider.