RESTITUTION FORM
Please complete this form and submit within 14 days of the last incident.
NAME
*
First Name
Last Name
POSITION
CUSTOMER NUMBER
*
SERVING BRANCH
*
TELEPHONE NUMBER
*
Please enter a valid phone number.
ADDRESS
*
Street Address
Street Address Line 2
City
County
Postcode
EMAIL
*
example@example.com
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PLEASE NOTE:
We will only consider claims in the format of the table below. Claims without supporting details, or related products not supplied by Menzies Distribution will not be considered. If we uphold your claim, the lost margin and/or fixed-rate HND payments will be credited to your account.
ISSUE DATE
TITLE
LOST SHOP SALES
LOST HND SALES
TOTAL LOST SALES
REDELIVERED HND COPIES
1
2
3
4
5
6
7
8
9
10
RETAILER COMMENTS:
Please state the nature of your claim. Note, we may request supporting details for HND claims.
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SIGNATURE
PRINT NAME
DATE
-
Month
-
Day
Year
Date
Submit
Should be Empty: