US-FLC63-250001 Cardio Resting ECG Rebate Form

Promo Redemption Information

Facility Information

Facility Name *This question is required.

Parent Organization

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State / Province *This question is required.

Postal / Zip Code *This question is required.

1. Contact Information

Contact Function/Title

First Name *This question is required.

Last Name *This question is required.

Phone Number *This question is required.

Tax ID *This question is required.

Email Address *This question is required. This question requires a valid email address.

2. Rebate Mailing Address

Facility Name *This question is required.

Attention

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State / Province *This question is required.

Postal / Zip Code *This question is required.

3. Purchase/Redemption Information

Baxter Rep Name

Distributor Company

Distributor Rep Name

Distributor Rep Email Address

Distributor PO#

4. Upload invoice(s)/proof of purchase and a completed W-9. *This question is required.(REQUIRED. Submissions without required documentation will not be processed.)

File: {{filename}} delete

5. Yes, I confirm that I have read and reviewed the Privacy Notice. *This question is required.

Yes, I confirm that I have read and reviewed the Privacy Notice.