Flight Centre Mastercard Notice of a Disputed Transaction Form

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Cardholder Name*

Customer Number*

First six digits of Card*

Last four digits of Card*

CARD QUERY

Is the card still in your possession?*

Yes No

Police Report Number*

Have you blocked or cancelled your card? *

Yes No

Before completing this form, please login into our Web Self Service centre and fill out our online form to cancel your card. Alternatively, call us on 0800 500 450 from NZ, or +64 9 580 7365 from overseas and follow the voice prompts.

Has the PIN been recorded anywhere (e.g. on the card, on paper)*

No Yes

Has the PIN been disclosed to a Third Party (e.g. family member, friend)*

No Yes

TRANSACTION DETAILS

Account Holder Name*

Person disputing the following transactions.

Account Holder Email*

Date/Time of Disputed Transaction*

Merchant Name (as shown on statement)*

Amount * NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Do you require additional rows to enter disputed transactions?*

No, I have entered everything. Yes, I need more rows.

ADDITIONAL TRANSACTION DETAILS

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

ADDITIONAL TRANSACTION DETAILS - Copy

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

Date/Time of Disputed Transaction

Merchant Name (as shown on statement)

Amount NZ$

REASONS FOR QUERY

Which of the following best describes the reason for your query?*

I did not authorise the transaction/s, nor did any other party to this account. Same transactions processed more than once by merchant. I did not receive the goods or services and have contacted/attempted to contact the merchant. (Please provide any proof of contact). A credit, as agreed with the merchant, has not been processed. I have cancelled the authority with the merchant but my account is still being charged. I used another method of payment for this transaction, not the above card, and I enclose my proof of payment. I was short-paid when withdrawing at an ATM. Please provide details.

Other:

ATM Withdrawal Transactions

Date/Time of Disputed Transaction

Amount withdrawn NZ$

Amount received NZ$

Date/Time of Disputed Transaction

Amount withdrawn NZ$

Amount received NZ$

IMPORTANT DETAILS OF THE SITUATION

Before we can investigate your query, we need to know the details of the situation and what contact has been made with the merchant/s involved. (You should attach copies of voucher/s and any other documentation that may assist with our investigation.*

DECLARATION

The facts provided by me are accurate to the best of my knowledge and I am not currently pursuing any other remedies for resolution.

Contact Number

Email*

Date*

Signature*

[clear]

Use your mouse or finger to draw your signature above