Cannabis Marketplace Payment Issue Report Form
Report payment problems related to your cannabis marketplace order or transaction.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Order or Transaction Reference Number
*
Date of Transaction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment Method Used
*
Please Select
Credit/Debit Card
Bank Transfer
Mobile Payment
Digital Wallet
Other
Type of Payment Issue
*
Please Select
Payment Not Processed
Duplicate Payment
Incorrect Amount Charged
Refund Not Received
Other
Amount Affected (in USD)
*
Describe the Payment Issue in Detail
*
Upload Screenshots or Receipts (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Resolution
*
Refund
Order Fulfillment
Account Credit
Other
Submit Report
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