Caps To Cash Enrollment Form

Caps To Cash Enrollment Form
Date*

MonthDayYear
Date
Organization Info*
Caps Coordinator Info*
Please select the AuBurn Pharmacy location in which you wish to enroll:*
501(c)(3) Status and/or Tax Exemption Certificate*

You may also mail, fax, or turn in your required documentation at any AuBurn Pharmacy retail location or to the Caps To Cash Program address.
Cancelof
AuBurn Pharmacy Caps To Cash Program

259 W Park Road, Garnett, KS 66032

capstocash@auburnpharmacies.com

Phone: (785)448-3600 - Fax: (785)448-3206
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