Refund

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					                               Refund
DATE: _________________

NAME: _________________________________________________________________

ADDRESS: ______________________________________________________________

CITY/STATE/ZIP: _______________________________________________________

TELEPHONE: ___________________________________________________________

REASON FOR RETURN: __________________________________________________

AMOUNT REFUNDED:___________________________________________________

           CASH: _______ CHARGE: _______ MAIL CHECK: ______

CUSTOMER SIGNATURE: ________________________________________________

EMPLOYEE SIGNATURE: ________________________________________________

				
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posted:9/2/2011
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