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Mac-Gray Company Refund Form


Date: __________________


Building Name or No. for Laundry Room: ______________________________


Name of School or Apt community: ____________________________________


Problem Machine:


Washer # ___________    Dryer # ___________    Changer #  ___________


Amount Lost: ________________     Nature of Problem: ________________

_____________________________________________________________________


Signature: ____________________________   Student # _________________


Building: _____________________________   Room # ____________________


Phone # _______________________________