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Vending Machine Refund Request


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

Your Name: *
Name of location of Machine: *
Your Address: *
Your City: *
Your State:*
Your Zip: *
Your Phone #: *
Your E-mail:
What kind of machine did you loose money in?:*
What was the selection # or product name that malfunctioned?: *
What is the amount that you lost in the machine?: *
What was the date on which you lost money in our machine?: *
Comments:



(Fields marked with * are required)




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