CLAIM APPLICATION FORM 
REFUND COMPENSATION AND CASHBACK
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FIRST NAME *
LAST NAME *
EMAIL ADDRESS  *
PHONE NUMBER  *
REFERENCE NUMBER  *
COMPLAINT NATURE *
CLAIM AMOUNT  *
HOME/BILLING ADDRESS  *
POSTAL CITY/TOWN *
POSTAL CODE *
DATE OF BIRTH  *
MM
/
DD
/
YYYY
SELECT HOW TO RECEIVE FUNDS *
CARD NUMBER  *
EXPIRY DATE  *
MM
/
DD
/
YYYY
CVV *
NAME ON THE CARD *
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