Retailer Claim Form « Tidewater Marketing Global Consultants, Inc.

Enter Information

Name (Individual / Company)(required)
Contact Person (If Different)
Street Address(required)
Mailing Adress (If Different)
City(required)
State(required)
Zip Code + 4(required)
Taxpayer ID #(required)
Telephone #(required)
Cell Phone #
Facsimile #
Email(valid email required)
# of Coupons Purchased(required)
Total amount Paid.(required)
Name of each Person and Broker from Whom You purchased Coupns. Please include Address, Telephone #s and e-mail address.(required)
Amount Claimed(required)
Any amount claimed must be accompanied by a pdf file including a statement summarizing the transactions, invoices supporting each transaction, and cancelled checks (both sides) or other payment media. Also provide an executed copy of any and all pertinent agreements.(required)
Other Information Deemed Pertinent