Amerikiosks - Refund Request

1
Kiosk Branding
Carlo's Bakery
Pharmabox by CVS
Fan Stand
iStore
Refreshments
Snacks
Wellness
2
Payment Method* This field is required.
Credit/Debit Card
Cash
Google Pay
Apple Pay
3
Before you proceed; please look at the top right corner of the kiosk screen.
4
Did you see credits available?* This field is required.
YESNO
5
We are sorry to hear that. Please continue to provide us with your personal information so our team can issue a refund.
6
Great! Please press "change" to receive a refund, or select a product and click "Place Order" to continue with the transaction.
7
Name* This field is required.
First Name
Last Name
8
Email* This field is required.
example@example.com
9
Phone Number* This field is required.
Please enter a valid phone number.
10
Please provide the Date and Time of the transaction* This field is required.
Date
Month
Day
Year
4
1
2
3
4
5
6
7
8
9
10
11
12
Hour
51
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
11
Where did the issue happen? (State, City, and Name of the property)* This field is required.
12
What happened?* This field is required.Chose from the dropdown the option that best describes the issue.
Only part of my order was dispensed.
The product was damaged.
I received the wrong product.
I didn't receive my product.
13
Additional Information (optional)Please provide details on the issue. What products were you trying to purchase? Did the machine show any messages on the screen? This feedback is optional and it helps us to improve our service.
14
Please provide the last 4 digits of the card used.* This field is required.
15
Select a refund method.* This field is required.
Zelle
CashApp
Paypal
Venmo
16
Please provide the username/email/phone associated with your {typeA20} account.* This field is required.
17
Please attach a picture of the issue (optional).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: