Coupon
Redemption Service
I. General Data
A. Name
of Store/Company:
B.
Store/Company Mailing Address:
C.
Address to which payments should be made:
Check here if same as Mailing Address above
P.O Box City State Zip
D.
Physical location of store. (Single store operators only). Attach store list for combined submissions.
Store
Name____________________________
Telephone #_____________________________
Street (NOT P.O
Box)_______________________________ Fax
#_______________________
City State Zip
E.
Type of entity: (check ONLY ONE)
____Proprietorship ____Partnership
_____Corporation State of Incorporation______________
F.
Coupons will be submitted: (check ONLY ONE)
____By Single Store ____Total Company How many stores?______
G.
Date business started or acquired: ____/____/____ (month/day/year)
Former
name (if applicable) ________________________________________________________
H.
Federal Tax I.D. or Social Security Number:
I.
Suppliers:
(Wholesale) (Secondary)
Name______________________________________Name______________________________________
Street/PO
Box ______________________________Street/PO Box________________________________
City,
State, Zip _____________________________City, State, Zip
_______________________________
Your customer number: ___________________________
J.
Gross annual sales: _________________
K.
Number of Employees: (Full and Part-Time)
____________
II. Store Data
A.
Type of store(s) (Complete the
following):
#
of stores Avg. selling
Number of checkout Avg. weekly
sq. ft/store aisles per store
open hours
1.
Conventional Supermarket______________________________________________________________
2.
Combination (Super)
Store______________________________________________________________
3.
Warehouse Store
______________________________________________________________
4.
Small Grocery ______________________________________________________________
5.
Convenience Store
______________________________________________________________
6.
Pharmacy ONLY
______________________________________________________________
7.
Liquor Store ONLY ______________________________________________________________
8.
Gasoline Service Store
______________________________________________________________
9. Other (Describe)
______________________________________________________________
B.
Check applicable product categories stocked:
___Baby
Foods ___Prepared Foods ___Produce
___Baking
needs ___Soft Drinks ___Delicatessen
___Candy/gum ___Soups ___Fresh Bakery
___Cereals ___Sugar/Syrup ___Cigarettes/Tobacco
___Coffee/Tea/Cocoa ___Household goods ___Liquor, excluding beer and wine
___Condiments ___Paper products ___Beer
___Crackers/Bread
Prod ___Pet Food/Products ___Wine
___Diet
Foods ___Soap/Detergents ___Pharmacy
___Canned
fish/meat ___Health/Beauty Aids ___Apparel
___Canned
fruit/veg ___Dairy ___Automotive
Supplies
___Snacks ___Fresh Meat ___Hardware
___Frozen Foods ___Salad Dressings, Mayonnaise and Oil
III. Coupon Data (Total for entity check off in section I.f)
A. Estimate average dollar value of weekly coupon redemptions:$________
B.
Coupon submission frequency:
____Weekly ____Monthly _____Bi-Weekly ____Bi-Monthly
C.
How are coupons submitted?
____Direct to Manufacturer __X__Clearinghouse _____Wholesaler
Name and address of Clearinghouse(s) (If
applicable):
(3rd Party Facilitator) (Clearinghouse)
Arizona Food Marketing Alliance International Outsourcing Services
Coupon Redemption Service 100 S. Alto Mesa Street
120
E. Pierce Street El
Paso, Texas 79912
Phoenix, AZ 85004
D. How often do you double/triple coupon:
___Never ___1-15 wks/year ___15/30 wks/year ___Over 30 wks/year
Individual
responsible for Coupon Redemption:
Printed
Name: __________________________ Title:
______________________________________
Email
address for the above:
_______________________________________________________________
Owner/Manager
certification: I hereby certify that all of the information provided in this
application is correct to the best of my knowledge. (Signature is mandatory
to signify certification)
Signed:____________________________________
Date:______________
Printed
Name:_______________________________ Title:_______________________________