Form Ogc-Sf-2005-01 - Vending Refund Policy And Request Form Page 4
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4Form No. OGC-SF-2005-01
Canteen
SNACKS, COFFEE, AND COLD VEND
Vending Refund Request Form
All refund requests are subject to review at the discretion of the Department of Business Services
(Please see Vending Refund Policy on the reverse side)
Name of person requesting refund: __________________________________________________________________
Identification #: ____________________________________________________________________________________
(UH ID#, Driver’s License#, etc.)
__ Student
__ Staff
__ Faculty
__ Other: ________________________________________________
(Company/Affiliation to UH)
If Staff or Faculty, please provide dept. name & mail code: ___________________________________________
Daytime Phone: ______________________________
Work Phone: ______________________________
Cell Phone: __________________________________
Pager: ____________________________________
(Provide area code with number if it is not a UH number)
Email: _____________________________________________________________________________________________
Building name where stated loss took place: _________________________________________________________
Room # or location in building: _____________________________________________________________________
Specify product type and Product Line of the machine: ______________________________________________
(i.e. Dasani Water in Coke Machine, etc.)
Provide the machine #: _____________________________________________________________________________
(if not numbered and there are multiple machines in the location, indicate 2
from left or other directions as needed)
nd
Day and Date of stated loss: ________________________________________________________________________
Time of stated loss: _________________________________________________________________________________
Did you call the Vending Services number on the machine to report a repair? __ Yes
__ No
Please provide a brief description of the specific problem with the machine and the reason for this
refund request: _____________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Refund amount requested: __________________________________________________________________________
Coke Product: (Please indicate the appropriate item(s))
Gums &
Hot
Item
Candy
Pastry
Snacks
Cold Vend
Mints
Beverage
Amount
$
$
$
$
$
$
Lost
Requestor’s Signature: _____________________________________
Date: ______________________________
Cashier: ___________________________________________________
Date: ______________________________
Vending Services Approval: ________________________________
Date: ______________________________
Note: Modification of this Form requires approval of OGC
Office of the General Counsel
Campus Vending Refund Policy & Request Form
OGC-SF-2005-01 Revised 09.01.06
Page 4 of 4
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