Page 1 of 2NameFirstLastEmail address*Phone NumberDoes The Machine Show Physical Damage?*YesNoDamage Description*Did a Product Fail to Vend?*YesNoTime of failureDate of failureMachine Location*Please Use Local landmarks (ex. PBIA Main Terminal)Product selection*Your Selection That Failed (ex. 6A)Amount Paid*Additional CommentsNextWere You Provided a refund?*YesNoNot SureWould You Like A Refund?*Typically If you paid by Credit / Debit and the Machine failed to vend the pending payment will not be processed. Please allow 3-5 business days for the transaction to clear. Terms may differ depending on your financial institution YesNoZelle Information*We process our refunds through Zelle: Phone or EmailBackSendThis field should be left blank