|
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 |