Primary Contact

Company
First Name*
Last Name*
Address
City
State	-- Select -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NT NS NU ON PE QC SK YT
Postal Code
Phone*	--
E-mail*

Offer Details

Offer Name
Offer Type	--Select-- Assembly Kitting Collating Coupon Clearing Data Entry Lettershop Merchandise Customer Service Rebate Web Services Sweepstakes Premium/Prize Procurement

Offer Dates

Start Date	-- (MM-DD-YYYY)
End Date	-- (MM-DD-YYYY)
Last Postmark Date	-- (MM-DD-YYYY)
Close Date	-- (MM-DD-YYYY)

Offer Specifications

Rebate Amount
or
Item Description
Item Dimensions	Length: Width: Height:
Item Weight
Circulation
Media Types	Tear-pad Thermal Web Submit - Printable form to be mailed into PMC FSI Online Magazine Other:
Estimated Number of Products Sold	Units (relative to this offer)
Estimated Redemption	Submissions / Responses
Valid With Only One Retailer?	Yes No
Which Retailer

Submission Requirements

Offer Form	Original Copy None
Receipt	Original Copy None
UPC	Original Copy None
Serial Number	Required Not Required
Acceptable Models / UPCs

Check or Mailer Type

Postcard	Yes No
Z-Fold or Insertable	Yes No
Envelope	Yes No
Corrugated Box	Yes No
Other

Funds

Rebate Funds	US Canadian
Consumer Monies	Checks/Cash: US Canadian   Credit Card: US Canadian

Non Compliance Type

Postcard	Yes No
Z-Fold or Insertable	Yes No
Customer Service Number	Yes No

Offer Limits

Limits for this Offer:	Per Person Household Address

Additional Data to Capture

Retailer	Yes No
Date Purchased	Yes No
Postmark Date	Yes No
UPC	Yes No
Serial Number	Yes No
Phone Number	Yes No
E-mail Address	Yes No
Closed Ended Question	Yes No
Open Ended Question	Yes No

Special Instructions