Inkjet-Cartridges-Refills
Order Cancellation Request

After printing and filling out this form, please fax (503-643-5379)
or mail it to us:    Inkjet-Cartridges-Refills
                                               10200 SW Eastridge Street, Suite #105
                    Portland, OR  97225

Office use only:

Date OCR Received _____________
Date Ordered/Shipped _____________
Initials __________

It is the responsibility of the customer to ensure receipt of this form by ICR.
A response will be emailed to you.

ICR Order #: ______________________________     Date of Order: __________________________

Cancellation Type: (please check one)
[  ] Cancel and issue refund         [  ] Cancel and issue in-store credit          [  ] Change order*
*If you choose this option, fill out both this Cancellation Request and the Order Form,
which you may find at https://epson-inkjet-cartridges-refills.com/order_form.htm (link).
Name (First and Last): Company:
Shipping Address: City:
State/Province: Postal Code: Country:
Phone # (with country/area codes, if appl.): Fax #:
Email address:

ICR Part # Description Quantity Price per Item Total Cost

    Shipping Method Originally Chosen for Order*: UPS or USPS (circle one)
Shipping Charge for Method Chosen:

Handling ($5.00 fee added to all international orders):

Original Order Total:
*I understand that I am responsible to pay for any charges incurred by Inkjet-Cartridges-Refills for packages that have shipped prior to the receipt of this form.
 
Credit Card #: Exp.: _____ Mo _____ Yr CVV #*:
Billing Address: City:
State/Province: Postal Code: Country:
Phone # (with country/area codes, if appl.):

PO # (if appl.):

*The CVV # can be found on the back of your card, above the signature area.

                                    I am the authorized account holder of the credit card listed above. 

I understand that this Order Cancellation Request will be processed according to
the Terms and Condition of Sale at https://www.epson-inkjet-cartridges-refills.com/terms.htm (link),
 including, but not limited to, any cancellation fees that may apply (see Point 3: "Price and Payment").
I have read, understood, and agreed to be bound by these Terms and Condition of Sale and the Return Policy
currently in effect at https://www.epson-inkjet-cartridges-refills.com/returns.htm (link).

Signed: ______________________________  Date: _______________________