OTH Mail In Rebate “MIR” Claim

* = Required

OTH Cust/Mbr:

Select One

Cust/Mbr ID#:

If Applicable

Name

First & Last Name

Phone #:

(###)###-####

Email Address

email@email.com

Billing Address:

street #/name, city, state, zipcode, country

MIR Type:

Select One

Upload Documents Here:

Info about the MIR:

Date MIR Created:

mm-dd-yyyy (Todays Date)

Electronic Signature

legal first & last name

Yes! I agree to the Statement

By checking "Yes" You understand that Not All Mail in Rebates "MIR" are not approved. OTH Accounting Dept has the final say on what is approved and what is not. The OTH Accounting Dept will contact you if any other info is needed.