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| Name: |
__________________________________ |
Date: ________________ |
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| Mailing Address: |
_____________________________________________________________ |
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_____________________________________________________________ |
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_____________________________________________________________ |
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| Telephone Number: |
_____________________________________________________________ |
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| E-Mail Address: |
________________________________ |
Sale #
_______________ |
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| Items to be
returned: |
1.
__________________________________________________________ |
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2.
__________________________________________________________ |
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3.
__________________________________________________________ |
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4.
__________________________________________________________ |
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5.
__________________________________________________________ |
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Visa ____ M/C ____ (check
one) |
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Credit Card #
for Refund: |
Number:_________________________ |
Expiry:
___/___ |
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| Reason For Return: |
_____________________________________________________________ |
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_____________________________________________________________ |
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_____________________________________________________________ |
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