Please fill out the form below to request a refund of your recent purchase:

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* 1. Your Full Name:

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* 2. Your sign up date (please note that all refund requests must be made within 30 days of your initial signup)

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* 3. Please provide the email address associated with your account or purchase:

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* 4. Please provide the dollar amount you are requesting to be refunded (in $US dollars):

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* 5. Reason for requesting a refund:

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* 6. Please check all that apply:

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