cosmocard® - Regress-Form

Dear customer,

apparently we could not statify with our service and a refund request has arisen from your side. We want to apologize for your efforts in any case!

Please provide as many informations as possible to not unnecessarily delay the process.

Error Description (at least 100 characters)

When (date and time) did the problem occurred?

Terminal number

Terminal-Location Description (at least 50 characters)

How much money did you deposited into the terminal?

Telephone number(s)

E-Mail-Address

Dealing with your data

To refund your objections, unfortunately, we also need sensitive / personal data from you. We assure you to deal responsibly with these data in any case and to delete these after completion of the operation as soon as possible.

Please enter your address

Name

Street

Postal code

City

Country

Please enter your banking informations

Account holder

IBAN

BIC