CUSTOMER REFUND REQUEST FORM

Name *

First

Last

Customer Code *

Physical Location *

Email *

Reason For Refund *

Date *

dd/mm/yy

Mode Of Repayment *

How you want to receive refund

Amount *

Bank Account or MOMO Number *

Account Name *

Name on your bank accout or mobile money number

Bank Name

Provide bank name if bank account is selected from mode of pament.