Verification Form

DATE * +

First Name *

Last Name *

Mailing Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

REQUESTED REFUND AMOUNT? *

Email Address *

Re-Enter Email Address *

TERMS AND CONDITIONS

CREDIT CARD DISPUTES: By requesting a refund from Divine Designs Salon Inc dba Divine Designs Salon & Spa (the "Company") I attest that the charge or charges which are being refunded or credited to my account have not been disputed by me with any credit card company and in the event that a dispute is later to have been filed, I agree that I shall be responsible for the reimbursement and payment of any disputed charges as well as all fees associated with the collection of such charges incurred by the Company, including reasonable attorney's fees. I also understand and agree that the final amount of the refund requested is subject to a verification and audit of the charges associated with this request and may differ from the actual refund either due or provided to me and that if the amount of the refund is different from the requested amount, I will be provided with an opportunity to either approve the amount prior to receiving the refund or withdraw this refund request entirely.

SOCIAL SITE POSTINGS: I further agree that this refund or credit is being provided to me as a settlement of a customer service issue which is being resolved to my satisfaction in its entirety by the issuance of same and will only be issued after I have removed any posting on any social site which may state to the contrary and any future postings with respect to my service visit either past, present or in the future shall not contain or insinuate any negative or disparaging comments about the Company on any public posting or website.

NON-DISPARAGEMENT: I further agree not publicly disparage, discredit, defame, or belittle (collectively, “Disparage”) the Company, its owners or staff or induce or encourage others over whom I may have control to disparage the Company, its owners or staff. For purposes of this Agreement, "disparage" means and includes, without limitation, any communication which (i) casts the other in what a reasonable person would construe as critical or negative, (ii) contains information that other persons could use to cast the other in what a reasonable person would construe as critical or negative; or (iii) discloses the business or financial practices or condition of the Company or disparages ongoing and future business relationships with any vendor, partner or customer.

VIOLATION OF AGREEMENT: I agree that if I violate this agreement, I shall be responsible for the reimbursement and payment of any refunded amount(s) as well as all fees associated with the collection of the refunded amount(s) incurred by Divine Designs Salon Inc DBA Divine Design Salon & Spa, including reasonable attorney's fees without prejudice of any rights by the Company to seek punitive action including additional damages from a violation of any of these provisions.

VERIFICATION OF CONTACT INFORMATION: By clicking on the I agree button below and printing my name, I agree to the terms herein and request that a refund or credit be issued in accordance with the terms as stated herein. If this refund is to be made by check, I request it be made payable to me and mailed to the address as noted above.

I AGREE

PRINT NAME *