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AMERICAN EXPRESS TRAVELERS CHEQUE RECORD

At Times of Purchase, Fill in Amount of Each Cheque and Last 3 Figures of Cheque Number, When Spent Fill in Date.

[[9 columned table]]
|      | LAST 3     |       |      | LAST 3     |       |      | LAST 3     |       |
|      | FIGS OF    | DATE  |      | FIGS OF    | DATE  |      | FIGS OF    | DATE  | 
| AMT. | CHEQUE NO. | SPENT | AMT. | CHEQUE NO. | SPENT | AMT. | CHEQUE NO. | SPENT |
|      |            |       |      |            |       |      |            |       | 
|      |            |       |      |            |       |      |            |       |
[[multiple blank rows]]

IMPORTANT...FOR PROMPT REFUND. If Cheques are lost and you need urgent funds, call at the nearest American Express Office (in the U.S. for address and telephone number call Western Union Operator 25) or wire American Express Refund Division, 65 Broadway, New York 6, N. Y. Give full serial numbers of Cheques lost, total amount lost, your address for contact and request an immediate refund. Otherwise send this slip at once to our Refund Division, after filling out the following information:

The following uncountersigned Travelers Cheques were lost, stolen or destroyed:

(List Serial numbers) ________________________________________________________

The loss occurred as follows: (Saw how, when and where) ______________________

Name ______________________
Address ___________________

It is also advisable to report the loss or theft of your Travelers Cheques to the Police of the city where it occurred.

Transcription Notes:
The table is empty The _____ represents lined area to be filled in