Chargeback Submission Form
Submitter Name
*
First and Last Name
Location
*
BD HQ
BD #7 Dunn
BD #6 Normandy
BD #5 103rd
BD #4 Atlantic
BD #2 Edgewood
BD #1 Moncrief
Chargeback Processed Date
*
-
Month
-
Day
Year
Date
Response Received No Later Than Date
-
Month
-
Day
Year
Date
Chargeback Claim #
*
Chargeback Amount
*
Memo or any details about the customer or transaction:
PHOTO OF CHARGE BACK LETTER 1st PAGE
*
Browse Files
Cancel
of
PHOTO OF CHARGE BACK LETTER 2nd PAGE
*
Browse Files
Cancel
of
PHOTO OF CUSTOMER RECEIPT
*
Browse Files
Cancel
of
Submit
Should be Empty: