GDK REFUND REQUEST FORM

PART 1 : Client Information

1) NAME OF APPLICANT...

2) COMPANY (If Applicable)...

STREET ADDRESS

3a) street/city...

3b) state...

3c) zip code...

Contact Information

4) phone...

5) alternate contact phone...

PART 2 : Order Information

6) ORDER DATE...

date posted to credit card...

5) ORDER NUMBER...

7) SERVICE or ITEM(s) Purchased...

8)

9)

10) PLEASE PROVIDE US WITH A STATEMENT AS TO WHY YOU REQUESTED A REFUND?

Refunds are handled on a case by case basis. Our Terms & Conditions

listed on our website which you agreed to clearly explain this.

By signing this form you understand that management will issue you

a refund at their sole discretion in accordance with the terms and

conditions stated on the web site.

PART 4 : Client Signature Information

11) YOUR SIGNATURE (typed and any GDK file number)...

12) DATE TODAY...

Please email completed form to: gdk@geraldkrug.com