Please provide the following contact information:

Billing Name
Billing Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Please provide the following information about your order:

	Order Information
Your Order #
Date Ordered
List Product Name

 

	Shipping Information
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Email Address

Does your list qualify for a credit/refund based on the above guidelines?:

Yes No

Please explain why your entitled to a partial refund and add any information or comments regarding your marketing campaign.