Account Cancellation Form - Super Replicas

Name: ________________________________________________________________________

Email address: _________________________________________________________________

Invoice number: _________________________________________________________________

Date of purchase: ____/________/______

The amount deposited:  $ _____________

The form of payment:  ________________

Reason for cancellation: ______________________________________________________________

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Our do you want the money refunded:_____________________________________________________

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Please give the details of the way the money will be received: __________________________________

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