Shopper Rebate Form Rebate Request Form Name* First Last Email* Email used with the rebatejet systemPhone*Your mobile phone number used to sign upDate of purchase* Date Format: MM slash DD slash YYYY Date you purchased the item on AmazonAmazon Order Number*Your Amazon Order NumberScreenshot of your Amazon Order*Accepted file types: jpg, gif, png, pdf.Take a screenshot of the Amazon order so we can verify you made the purchase. Please include the price paid in the photo.Picture of the product in your possession*Accepted file types: jpg, gif, png, pdf.Take of a photo of the product in your possession. Paypal Email Address* Enter Email Confirm Email As our check system is no longer functioning, we will send all rebates via Paypal.Rebate Amount Due*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
