Grocery and Gas Rebate Order Form
Name: ___________________________________________________
Company Name: ___________________________________________
Name on the Certificates: ____________________________________
Address to send the certificates: _______________________________
_________________________________________________________
MINIMUM ORDER OF EACH TYPE OF CERTIFICATE - 100 CERTIFICATES
Gasoline Rebate Certificates
Number
________
$100 rebate certificates at $15 each
$_______
________
$150 rebate certificates at $20
each
$_______
________
$300 rebate certificates at $25
each
$_______
________
$500 rebate certificates at $30
each
$_______
TOTAL Gasoline certificates (must add to a minimum of
100) $ __________
Grocery Rebate Certificates
Number
________
$100 rebate certificates at $15
each
$_______
________
$150 rebate certificates at $20
each
$_______
________
$300 rebate certificates at $25
each
$_______
________
$500 rebate certificates at $30
each
$_______
TOTAL Grocery certificates (must add to a minimum of 100)
$ __________
TOTAL DUE $___________
Payment:
Card Number: ___________________________________________
Expiration Date: ________________ Security Code: ____________
Name on the Card:________________________________________
Billing Address: __________________________________________
_______________________________________________________
Signature: ______________________________________________
Fax to 678-969-2791 or email to ruthking@bventures.com
BUSINESS
VENTURES CORPORATION