CREDIT & GIFT CARDS DISPUTES

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Manager's Name Manager's Name * First Last
Date Date * / MM / DD YYYY
Store Location *
Contact Information

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Guest Name Guest Name * First Last
Phone Phone * - ### - ### ####
Email *
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Process Base

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Transaction Date Transaction Date * / MM / DD YYYY
Server's Name: *
Check # *

If you don't know the check number Please Just add 0000.
Card Type *
**** Last 4 digits *
Transaction Amount * $ Dollars . Cents
Alternate Amount * $ Dollars . Cents
Reason *
Comments: