Vending Machine Refund Request Form

Please complete this form to request a refund if a vending machine malfunction on campus caused you to lose money.

Name*
First Last
Phone*
Please enter a mobile phone number.
Email*
Campus Box Number

Please be sure to specify if you have an NRH box.
Please identify the type of machine you are reporting.*
Where is the machine located?*
Refund Amount*

How much money did you lose?
Refund Reason*
Please tell us what happened when you lost your money. This information will be reported to the machine owner to help diagnose and prevent the problem from reoccuring.