Purchase Submission

PURCHASE SUBMISSION

NOTE:

FIELDS IN ALL CAPS ARE REQUIRED

Enter your details in the form below to have your account credited with rebates accumulated by your purchases with your Affiliated Businesses.

FIRST NAME:
LASTNAME:
EMAIL ADDRESS:
PHONE NUMBER:
YOUR POSTCODE:
AFFILIATED BUSINESS NAME:
BUSINESS POSTCODE:
Business phone number (if known):
Business email (if known)
DATE OF PURCHASE:
AMOUNT OF PURCHASE $:
PURCHASE DOCKET REFERENCE NUMBER:
ENTER YOUR DESIGNATED CHARITY/ORGANIZATION:

All submissions are processed in the billing period they are received in.

Purchases made in a previous billing period will be reflected in the current statement.

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