THIS IS NOT A REBATE SUBMISSION FORM.

Rebate Forms can be acquired thru the store where you purchased your product.

Only fill out this form if you have not received your rebate after
the time period indicated on the rebate form.

CUSTOMER & PURCHASE INFORMATION

Promo Code	*
Contact Name
Day Telephone
Address
City
State
Zip Code
Country
E-mail Address
Dealer Name
Purchase Date	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2007 2006
Part No.	(Ex. TFD120U2, MDU500)
Serial No.	(Ex. 100152)
Date Rebate Form was Mailed	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2007 2006
Amount of Rebate	$10 $15 $20 $25 $30 $40 $50 $60 Don't Know

Please click on 'Submit' only once.