(DRAFT) ACCU - Keeler Rewards Club Redemption Form

Keeler Rewards club - Redemption form

If you are part of a multi-branch facility, the main location of that facility will determine where the product will be shipped. Points must be redeemed before August 31, as points do not roll over. This form collects information only.
Your details
Account number
Name of practice
Name of manager or physician
Email of manager or physician for account queries
example@example.com
Shipping address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Choose your reward
Check the reward you would like to redeem, then specify the quantity. For rewards with options available, please specify.
Tier 1 (12,000 points)
Tier 1 - Reward choice / Qty / Other comments
Tier 2 (24,000 points)
Tier 2 - Reward choice / Qty / Other comments
Tier 3 (48,000 points)
Tier 3 - Reward choice / Qty / Other comments
Tier 4 (96,000 points)
Tier 4 - Reward choice / Qty / Other comments
Tier 5 (192,000 points)
Tier 5 - Reward choice / Qty / Other comments
Approval
Approved by (sales rep)
Signature of manager or physician
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Keeler Rewards club - Redemption form