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Vending Refund System

Instructions:
Please fill out the form below and click the submit button.

Your Name:	*
Company Name:	*
Address:	*
City:	*
State:	*
Zip:	*
Phone:	*
Fax:
E-mail:	*
What machine did you loose money in?:	*
What was the selection # or product name that malfunctioned?:	*
What is the ($) dollar amount lost in the machine?:	*
What was the date on which you lost money in our machine?:	*

(Fields marked with * are required)