Coupon Code Request Form
Please complete the following form, paying special attention to the required information.

Required Information
E-mail Address:
UPC or EAN of Product(s):
Exact Company or
Manufacturer Prefix:
(if known)
Pick a Six-Digit Offer Code:
(Used To Track Coupons
Within The Retail Chain)
 Units Free
Purchase Requirements:
(What does a customer need to do to get the above value?)

Requested Information
Exact Product Name:
Manufacturer Name:
Family Code:
(change only if you were provided one)
(Please use 010 if your coupon is for PLCB)

Optional Information
Expiration Date:
/ /
Can The Coupon Be Doubled?
Yes No
Combinations, If Any:
(I.E Buy Product A And
Get $1.00 Off Product B)