The document is a dispute form submitted to Bank of China's credit card customer service center. The cardholder is disputing a transaction and requesting either a copy of the transaction receipt or to dispute the transaction. If disputing the transaction, the cardholder can either pay now and request a refund if not liable, or withhold payment until the investigation is complete and be liable for fees if found responsible. The cardholder is disputing based on unauthorized use of the card. They have enclosed copies of the front and back of the card and are requesting the disputed amount be removed until the investigation concludes.

1. To: Bank of China Credit Card Customer Service Centre Fax Number: 010-8297 0255
GWIC Cardholder Dispute Form
Credit Card No. Cardholder Name Statement Date Tel. No.
Transaction Date Merchant Name Transaction Amount
Part 1 :
Requesting for transaction record : I did authorize the above transaction(s). I would like to request the copy of
transaction receipt for my reference only. I agree to pay for the copy retrieval fee of HKD40/ USD5/ EUR4/ GBP3/ AUD5,
please debit my account stated above.
Requesting for dispute : I would like to request the dispute of transaction. (Please fill in Part 2)
Part 2 :
I will settle the transaction(s) first, please refund to me if I am not liable for the transaction(s).
I will not settle the transaction(s), please put the transaction on hold until the investigation results are known. I
understand that I will be liable for the disputed item together with the handling fee (if any) and accrued interest, if the
transaction(s) is proved to be authorized by me.
I would like to dispute the item(s) based on the following reason(s): (Please tick the appropriate box)
1. Unauthorized Use I did neither authorize nor participate in the transaction(s). My card was in my
possession at the time of the questioned transaction.
(Please enclose with the copies of front and back of your card)
2. Duplicated Charge I only authorized one transaction but the merchant charged more than once.
3. Participated in ____ I did authorize in _____ transaction(s) for amount $_______________ at the
Transaction(s) Only merchant, but I neither authorize nor participate in the above transaction(s) and my
card was in my possession at the time of the questioned transaction.
4. Incorrect Amount / Transaction amount should be $ _______________ at __________ (Currency).
Transaction Currency (Please enclose with your copy of transaction receipt)
5. Paid By Other Method I have settled the transaction(s) by □ cash □ others ___________________
(Please enclose with the copy of payment receipt)
6. Credit Not Received I have received a credit slip issued by the merchant but no refund is received.
(Please enclose with credit slip or any supporting document)
7. Non-receipt of Goods / The merchant was unable or unwilling to provide the ordered merchandise / services
Services to me, I have attempted to resolve with the merchant but in vain. (Please enclose
relevant supporting document stating the delivery date, etc…)
8. Cancelled Recurring I have informed the merchant to cancel my monthly/yearly agreement by written
Services request on __________(date) Nevertheless, my account was still billed.
(Please enclose the cancellation letter / form)
9. Cancelled Reservation at I have made a room reservation at the above Hotel but cancelled at __________
Hotel (am/pm) on (date)__________. I was given a Cancellation No._______________
10. Non Receipt of Cash at I did authorize and participate in the transaction(s) but □ did not receive cash
ATM OR □ received a partial amount $ _______________ from the ATM.
11. Others
Cardholder Signature 签署：
签署： Date 日期：
日期：
(Signature must be same as the one on Application Form 签字式样须与申请表相符)
Remarks: 1. I understand and agree that I must notify Bank of China in writing within 30 days from the date of the Statement for the contrary.
Otherwise, I shall be liable to the dispute transaction(s).
2. I understand and agree to pay for the handling fees stated in “Great Wall International Credit Card Fees Schedules” in result that I am
liable for the aforesaid transaction.
送：中国银行信用卡客户服务中心 传真机号码： 010-8297 0255

2. 中国银行长城国际卡问题签账查询表格
中国银行长城国际卡问题签账查询表格
争议理由中文译本 (只供客户参考
Chinese Translation of Dispute Reasons 争议理由中文译本 (只供客户参考)
只供客户参考)
卡号 持卡人名称 结单日期 联络电话
交易日期 商户名称 交易金额
第一部份:
第一部份:
要求查单 : 本人曾授权上述交易，只要求索取签购单副本作存根。夲人同意支付 40 港元/5 美元/4 欧元/3 英镑/5 澳元查阅签购单手续费。
要求查询问题签帐 : 本人要求查询问题签帐。 (请填妥第二部份)
第二部份:
第二部份:
夲人会先行缴款, 如发现非本人交易，请退款到本人户口。
夲人不接纳先行缴款，请扣起有关交易款项。如证实夲人需负责上述交易，夲人同意支付有关交易帐项并承担因暂缓缴款所产生之利息及手
续费。
夲人要求查证以上交易，原因如下：请选择以下指示 “√”)
争议理由
Dispute Reason 争议理由 争议内容
Descriptions 争议内容
1. Unauthorized Use 本人无授权上述交易，此卡在问题交易发生时一直未有遗失
无授权上述交易 (请附卡正背面副本)
2. Duplicated Charge 本人只授权一笔交易，但商户重复收款
重复收款
3. Participated in _____ 本人在上述商户只授权­­ 笔交易，金额为$______________。 但
Transaction(s)
Transaction(s) Only 夲人无授权上述交易。在交易时，夲人持有上述信用卡。
只授权 _____ 笔交易
4. Incorrect Amount / Transaction 交易金额应为 $ __________ 的 __________ (货币)
Currency (请附签购单据副本)
金额不符 / 交易货币不符
5. Paid By Other Method 本人已用其它方式付款 □ 现金 □ 其它 __
已用其它方式付款 (请附收据副本)
6. Credit Not Received 本人收到商户签发的退款单，但该退款至今仍未記入本人账户内
收不到退款 (请附退款单副本或任何证明文件)
7. Non
Non-receipt of Goods / Services 商户未能或不愿意向本人提供商品或服务，本人已尝试联络商户解决
未有收到订购之商品或服务 但不成功
(请于附有关文件注明送货或提供服务日期等…)
8. Cancelled Recurring Services 本人已于 __________ (日期) 以书面向上述商户提出取消自动转账授
已取消服务 权，但该商户未有按照办理(請附上有關通知商戶取消之證明)
9. Cancelled Reservation at Hotel 本人确曾向上述酒店订房，但本人已于 _______________(日期及时
已取消预订房间 间)向酒店取消订房并取得一取消号码 ____________
10. Non Receipt of Cash at ATM 本人曾授权上述交易，但 □ 自动柜员机没有出钞
自动柜员机没有出钞 或 □ 自动柜员机只提供部份钞票 $ _______________
11. Others
其它
备注： 1. 本人明白并同意所有问题交易必须于结单日期起计 30 天内以书面通知中国银行，否则本人须对该
项交易负责。
2. 本人明白并同意如查单结果证明本人须对该项交易负责，本人须同时负责 “長城國際卡费率表”
列明之查阅签购单手续费