Company Name
(required)
Request Type
(required)
Refund Request
Equipment Issue
Equipment Type
Vending Machine
Coffee Equipment
Microwave
Ice Dispenser
Water Dispenser
Other
Vending Issue Type
Glass Broken/Pushed In
Coil/Selection Not Working
Credit Card Reader
Not Accepting Bills
Not Accepting Coin
Not Giving Proper Change
No Power
Other
Asset Number
(required)
CVC Number
(required)
Name CustomField
Name
(required)
Preferred Contact Method
(required)
Phone
Text (Non-Landline Only)
Email
Email
(required)
Phone Number
(required)
Refund Type
Paypal
Venmo
Other
Method Used to Pay
Credit
Cash
Coin
N/A
Requested Refund Amount
PayPal Email / Venmo Username
Description
(required)
Attachment
RSG Line of Business
Markets
OCS
Vending
All
RSG Division
Continental
CoinOP
Cuyahoga
FranklinServices
NY
CanteenIndiana
SouthBend
Lebanon
TerreHaute
MIL
CTI
Brewmaster
FortWayne
Muncie
Indianapolis
Lafayette
Buffalo
Rochester
Elmira
Point of Contact
E-mail
Phone Call
Text
QR Code
Website