Please allow 12 weeks from the date of your rebate submission before using this form. This form is not a substitute for mailing the completed rebate claim, receipt, and your original UPC code. Important: Please enter your contact information exactly as written on the Rebate Claim Form Contact Rebate Services Customer Information First Name Last Name Daytime Phone # Street Address City State/Province Please Select AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY District of Columbia Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia N.W.T. Ontario Quebec Saskatchewan Yukon Puerto Rico Virgin Island Guam American Samoa Palau Postal Code Country Email Address Rebate Information Product Name Place Purchased Please Select AAFES BestBuy Circuit City FredMeyer FutureShop Micro Center Navy Exchange Office Depot Office Max RadioShack Staples Target On-Line (I/OMagic) Frys Tiger Direct Other Costco Ace Hardware DELL Other Date of Purchase (mm/dd/yy) Rebate Amount Please Select $5.00 $7.00 $10.00 $15.00 $20.00 $22.00 $25.00 $30.00 $35.00 $40.00 $45.00 $50.00 $60.00 Other