Ticket refund form

To the Head of the Moscow Public Foundation

support of culture and development of contemporary art

Kiseleva V.N.

От:____________________________________________________

Адрес проживания:______________________________________

______________________________________________________

Паспорт: Серия________________№_______________________

Contact phone number :____________________________

APPLICATION

Please return the money to the payment card

___________________________________________

(map name)

№
of the map:

*

*

*

*

*

*

*

*

( Specify the number of the payment card from which the order was paid. First 6 and last 4 digits)

For paid tickets through the website

_________________________________________________________________

В сумме­­­­­­­­­­­­­­­­­­­_______________________ (________________________________________) руб.

(Amount in words)

Транзакция №______________________Заказ №________________________

На мероприятие________________________________________________________________

(name of activity)

________________________________________________________________________________________________________

(date of event)

В связи__________________________________________________________________________________________________

(specify reason))

________________________________________________________________________________________________________

Date “______”__________________ 20_____.

Caption
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