Sign Up with Refund Retriever!

Thank you for your interest! Please download our PDF signup sheet and fax it to 1 (800) 699-0329. For your convenience, it's available in these formats:

PDF

DOC

RTF

You'll be hearing from us shortly after we receive your information, in order to finish setting up your account. Thanks again!

Sign Up with Refund Retriever!

To get signed-up with us immediately, please use the form below. There's also a fax form available. See below.

About You

Organization:
Contact Name:		Email Address:
Address:
City:		State: AL AK AR AS AZ CA CO CT DC DE FL FM GA GU HI ID IA IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY	Zip:
Phone:	(extension)	Fax:	(extension)
Are you a member of the AMPC? Yes No		Were you referred to us by one of our current clients? If so, who?
Anything else we should know?

Shipping Info
For each account (you may list up to 12), please give the account number, the name of the carrier, and whether or not this account is registered for Billing Online.

More than 5 accounts? That's fine. Please simply fill out the form once more.

Authorization

We hereby authorize DHL, FedEx, and UPS to share our shipment information with Refund Retriever for the sole purposes of tracking on-time delivery of our shipments. Our signature below does not commit our company to any payments, and we will pay Refund Retriever 50% of any refunds discovered by Refund Retriever.

Print-and-Fax Version

As an alternative, you may also feel free to download this form and fax it to us at 1 (800) 699-0329. For your convenience, it's available in these formats:
    PDF
    DOC
    RTF