1023 NE 43rd Street
Seattle, Washington 98105
(P) 1-800-426-9883
(F) 1-800-888-8124

To Whom It May Concern:

By this memo, we authorize IPS Rebates to receive data reporting relative to our distributor purchases, so that IPS Rebates can calculate, invoice, collect, and distribute rebates from manufacturers.

Signature

Date

Print Name

Title

Organization Information
Organization Name
Mailing Address
Street
City
State		Zip	-
Location Address	(if different than above)
Street
City
State		Zip	-
Phone	--	Fax	--
Email

Primary Food Wholesale Distributor(s)

1.	Distributor Name
	City		Phone	--
	Account Number(s) Separate account numbers with commas.	(Maximum characters 135. characters left).

2.	Distributor Name
	City		Phone	--
	Account Number(s) Separate account numbers with commas.	(Maximum characters 135. characters left).

3.	Distributor Name
	City		Phone	--
	Account Number(s) Separate account numbers with commas.	(Maximum characters 135. characters left).

To complete your enrollment, sign and fax this form to 1-800-888-8124.

www.ipsrebates.com