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Reimbursement Request Form
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Agent NPN: _________________________________________________________________________
Agent Phone: _______________________________________________________________________
Agent Email: ________________________________________________________________________
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Total Receipts Attached: ____________________________________________________________
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** By signing this form, you agree to the terms and conditions of the program and that all marketing must be conducted in compliance with all applicable federal and state laws. Typing your name is equivalent to a signature. I have received pre-authorization prior to my order placement.**
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Return this request for by fax at attention: Marketing Mania (866) 599-3390 or this email: jan@gordonmarketing.com