Transaction - PAY SYSTEMS

Event

Name of event*

Transaction date: *

Time of transaction *

Purchase amount: *

Purchased with: *

Purchased at: *

ID# Token vending machine

Further details of exact location token vending machine

Successful transaction?

Did you make a succesful transaction after the failed transaction?*

Date of successful transaction:

Time of successful transaction

Amount of successful transaction:

Service?

Did you make a call to the service number stated on the machine? *

Did you have any contact with a service employee during the event? *

Name of staff member

Description of situation

Contact details

Salutation: *

Initials: *

First Name: *

Last name: *

Adress: *

Zip code: *

Residence: *

Land: *

Phone number: *

Email: *

Bank account number:

Write-off

“We can only process your application if we have a print screen or scan of the transaction details of the relevant transaction (s). Minimum IBAN/BANK details should be readable. If it concerns a cash transaction, then a copy or scan of your bank card with IBAN is sufficient. Upon receipt of your application, one of our employees will request this information from you by e-mail.”

Upload proof:

I hereby declare that all information stated above has been truthfully and correctly submitted.

Event

Successful transaction?

Service?

Contact details

Write-off

Verification