Remittance Form

What is your three letter Organization Code?*
(Refer to the settlement email for your Organization Code.)
Make Check Payable to:*
Please type the name of your Organization exactly as it should appear on your rebate check so your treasurer will be able to deposit it.
Please indicate if check will be mailed to a home or your organization's office:*
- Home
- Office
Please type the full Name and Mailing Address for the location where we will mail your rebate check.
Name:*
Phone Number (required by our bank)*
To the Attention of:
Address*
Street Address Address Line 2 City State ZIP Code
IMPORTANT NOTE: Please give careful consideration to who opens the mail at the address you provide and be sure they know what to do with the check! A $25 processing fee is charged to replace a rebate check.
Checks expire after 90 days.
Submitted by Name*
Submitted by Email*
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