Vending Machine/Washer/Dryer
Refund & Request for Service Form

Please use this form to report a problem with vending or laundry machines or to request a refund for money lost due to a malfunctioning vending or laundry machine. If you are only reporting a malfunctioning machine, then only section 1 needs to be completed. If a refund is requested, then the entire form must be filled out.

Section 1: Report a Problem

Name:

 
E-Mail Address:
 
Machine Location:
 
Type of Machine:




 
Description of Problem:
 
If other, please specify:
 
 

Section 2: Request a Refund

Refund Type Requested:
 
Amount (US $):
$
 
Phone Number:
 
Campus Address
 
- OR -
 
Home Address:
City:
State:
Zip:
 
 
 

The request has been sent via email to the proper people.
A copy of the email has been sent to:

Please click Finish to leave the Request for Service Form



   
Key fields are missing values.

Please fill in the following fields: