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AMERICAN EXPRESS TRAVELERS CHEQUE RECORD

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

[[nine column table]]

|AMT. | LAST 3 FIGS. OF CHEQUE NO. | DATE SPENT | AMT. | LAST 3 FIGS. OF CHEQUE NO. | DATE SPENT | AMT. | LAST 3 FIGS. OF CHEQUE NO. | DATE SPENT|
|   |   |   |   |   |   |   |   |   |

[[/nine column table]]

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 the following information:

The following uncountersigned Travelers Cheques were lost, stolen or destroyed:
(List Serial Numbers) [[blank]]


The loss occurred as follows: (Say how, when and where) [[blank]]


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

Name [[blank]]

Address [[blank]]

Transcription Notes:
looking at advanced rules, blank boxes dont need to be transcribed, not sure about the blank lines though *Note: document is a blank form for the tracking of travelers' cheques and instructions for claim of lost cheques.