BOC CREDIT CARD

24/03/2015

1 0 : 0 7 : 1 4 AM

e
Att ntion

PAGE

1/001

Fax

P a x

Server

No. 2296

Cardholder Dispute Form

-Credi* C a j ' d N o .

Cardholder N ainc

Transaction Date

Merchant N ame

T e l . N o.

StatcmcW Date

Transaction Amount

Part I )
'1

would like to dispule llie ite m(s) base d on the fo]lowing re ason(s):(Ple ase

tick the appropriate

box " ^'J

*
- K// m-'C
(M
Unauthorized Use - Internet / Mailing Order/ Pho ne Order transactio n o nly I neither iiutho fized no r participated in the above [ransaclio n(s;). My card ma in niy
possession at the time o f tlie queslio iied transaclio n. (Phase enclo se co py o f (he front md back o f your

airdj

...........H............1.'.........................^^^.....$.1.......7^
(Pflh
Participated in

Traiisactioii(s) Only - I did authoi ize

pailicipated in the above transact ion(s) and my card was inmy

aulhoiizcd

iransactionCs) for amounl $

at the above merchant, but I neither authorized nor

poss
e ssion at the time of the questioned U'aiisaction. (Plcrfse enclose copy ofthe

sale s slip for the

(msactm)

[understand that the captioned credit card account may be required lo

cancel and reissue with a new fuxoum number.

-ffi > )3
Duplicated Charge

ony

aulhoi ized one U'im saction but ihe merchanl charged m ore than once.

/-^$
-
Incorrect Amount / Transaction Currency

(
(

Transaction amount shouid be $

-Transaction currency

in

selecting ti'iinsKction currency.

-
Paid By Ot her Means -1 have sellled ihe transacUon(s) by

cash or

(Currency),

(Currency) was not agree lo use, merchant did not offer a choice to me for
(Pkase enclose copy oft he t mnsnct ion receipt )

_. (Pknse enclose copy oft he payment

receipt )

'11
Credit Not Receive: I have re ce ive d a credit slip issue d by the merchant but no refund is received. (Plam e nclose

llw cre dit slip or any supporlins

docum
e nl)

ffi >

Non-receipt of Goods / Se rvice s The merchanl was unabb or unwilling

merchanl but in vain. (PJe nse - enclose orde rre coni

to provide the ordered me rchandise / se rvice s lo me, I have aue nipte d to resolve with the

with the merchimdise/services

dcUmy

date )

I Type of ordered merchandise or serv ices

:/Mei-chant agreed merchandise / serv ices deliv ery date

.
.

()ilffiWW >(

Cancelled Recurring Services I have informed the mercham lo cancel my direci debit authoiization agreement on
.still billed. (Pkase e nclose the amcellafm

(date). Nevertheless, my account was

e
e
l tt r/form)

()

Cancelled Reservation at Hotel have made a room reservation at the nbove Hotel but cancelled al

(ani/pm) on

(date). I was given a

Cancellation N o.

Others, ulcasg specify:

qyuD
'' e
I will settle above Ii ansRclion(s) first, please refund lo me i f I am iioi liable for the transaclion(s).

^K-
I will n o l settle the transaction(sX please put the transaction on hold until the investigation results are known. I understand that I w i l l be liable for tlie disputed item
together with the handling fee ( i f nny) and accru&d inleresl, il" Ihe IransaclionCs) is proved to be authorized by me.

CardholderSignalure:

Date:

(+SO/Sipaiure must be sam e as the one on the back of your credit c a r d )

c n o i i j o j 30530