BOC CREDIT CARD 2 4 / 0 3 / 2 0 1 5 1 0 : 0 7 : 1 4 AM PAGE 1 /001 Fax S e r v e r

�� ���Attention � � � P a x No. � 2296 �

持卡人問题簽帳表格Cardholder Dispute Form

信用卞-帳號Credi* Caj 'd No. 持卡人姓名Cardholder Nainc 月結雜日期StatcmcW Date 聯 絡 爾 話 T e l . No .

簡戶名稱 Merchant Name 交易日期Transaction Date 交易金额 Transaction Amount

甲部（Part I )

���'�������������1 would like to dispule llie item(s) based on the fo]lowing reason(s):(�������Please tick the appropriate box " ^'J

•���* - K�����/��/ m������-��������������'���������C

(猜M上信用卡的正面和背面的影印副本）

Unauthorized Use - Internet / Mailing Order/ Phone Order transaction only � I neither iiuthofized nor participated in the above [ransaclion(s;). My card ma in niy

possession at the time of tlie queslioiied transaclion. (Phase enclose copy of (he front md back of your airdj

.......卫授榴一....餓交易人在上述簡后H授權............筮交1.'...金額爲.......―............°...很；^^^無授植上述交显..。...；£$.髿』1，...本.人持.奋.上述信用.7^丄

(請Pflh已授榧的交易簽購單據副本）

Participated in Traiisactioii(s) Only ；- I did authoi ize iransactionCs) for amounl $ at the above merchant, but I neither authorized nor

pailicipated in the above transact ion(s) and my card was in�my possession at the time of the questioned U'aiisaction. (Plcrfse enclose copy ofthe sales slip for the

aulhoiizcd (msactm)

：本人明白上述卡帳戶有可能豁要終止，並安排捕發一張全新卡號之信用卡。[understand that the captioned credit card account may be required lo

cancel and reissue with a new fuxoum number.

•靈菠收款：-本人只授ffi—鼙交易 > 但簡)3敏湲收款。

Duplicated Charge ；【on】y aulhoi ized one U'imsaction but ihe merchanl charged more than once.

• 金 额 不 符 / 交 易 貨 幣 不 符 ： - 交 易 ^ 額 應 爲 $ 的 (货幣）。

-本人不同意以 (貨幣）進行交易，商户沒街給我選撣交易之貨幣。（請附上簽購單據副本）

Incorrect Amount / Transaction Currency ： • Transaction amount shouid be $ in (Currency),

-Transaction currency (Currency) was not agree lo use, merchant did not offer a choice to me for

selecting ti'iinsKction currency. (Pkase enclose copy ofthe tmnsnction receipt)

•已用其它方式付款：-本人巳用其它方式付款•現金•其它 。（請附上收據副本）

Paid By Other Means �-1 have sellled ihe transacUon(s) by • cash or • _„. (Pknse enclose copy ofthe payment receipt)

•收不到退款：本人收到商戶發出的返款單'但該11款至今仍未記入本人帳戶內。（識时上退款單副本或任何證明文件）

Credit Not Receive: I have received a credit slip issued by the merchant but no refund is received. (Plam enclose llw credit slip or any supporlins documenl)

•没有收到訂購之商品或服務：ffi户不能或不願意向本人提供簡品或服務 > 本人已臀試聯络商户解决但並不成功。（請附上顿文件註明送貨或提

供服務日期等…）

Non-receipt of Goods / Services � The merchanl was unabb or unwilling to provide the ordered merchandise / services lo me, I have auenipted to resolve with the

merchanl but in vain. (PJense- enclose orderreconi with the merchimdise/services dcUmy date)

• 訂購簡品或服務I Type of ordered merchandise or services ： .

• 簡户同意之送貨或服務据供期:/Mei-chant agreed merchandise / services delivery date ： .

•已取消服務：本人已於 (曰期)以書面向上述商户提出取消ilffiWW帳授權 >但該商户没有按照辨现。(請附上有關通知簡戶取消之證明）

Cancelled Recurring Services ： I have informed the mercham lo cancel my direci debit authoiization agreement on (date). Nevertheless, my account was

.still billed. (Pkase enclose the amcellafm letter/form)

•已取消预訂房間：本人確曾向上述酒店訂房，但本人已於 (日期及時間)向酒店取消訂房並取得一取消號硕； 。

Cancelled Reservation at Hotel ：【have made a room reservation at the nbove Hotel but cancelled al (ani/pm) on (date). I was given a

Cancellation No.

n 其他Others, ulcasg specify: —--―

乙部qyuD •本人會先行'微歆上述之交易，如發现非本人交易，請退欷到本人戶'口 e

I wi l l settle above Ii ansRclion(s) first, please refund lo me i f I am iioi liable for the transaclion(s).

•本人不接納先行徽款，凍結有關交易款項。如証^本人需龠K上述交•本人同意支付有關交易帳項並承擔因暫緩繳款所蔬〈々-之利悤及手續费

I wi l l nol settle the transaction(sX please put the transaction on hold until the investigation results are known. I understand that I w i l l be liable for tlie disputed item

together with the handling fee ( i f nny) and accru&d inleresl, i l" Ihe IransaclionCs) is proved to be authorized by me.

持卡人簽馨CardholderSignalure: 日期Date:

(簽名必須與信用+背後之簽名式樣•SO/Sipaiure must be same as the one on the back of your credit card) c n o i i j o j 30530