Blue Light Card Refund – CB AM4 Forms

Form to Complete

Blue Light Refund Form

This form is to reclaim the cost of the Blue Light Card, (£4.99).

For us to process this, you will need to have been with us employed for 6 months.

Simply complete the form, upload an image of your card, and submit.

Form Name

Intro-Read *

Name *

First

Middle

Last

Which office / department do you work with? *

Employment Start Date *

Blue Light Card Expiry Date *

Blue Light Card Number *

Card Image *

Click or drag a file to this area to upload.

Please upload an image of the front of your card.

Statement *

I am claiming this cost as one I have already incurred (£4.99). I understand I can only claim for one membership for each 2 year period. This is not a replacement for a lost or stolen card.

Signature *

Clear Signature