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All fields marked with * are required.


C-Store Location Information


Store Name*

Federal Tax ID*

Grocery Distributor Name
Grocery Distributor
Account Number
Grocery Distributor
Contact Name
Grocery Distributor
Phone
Grocery Distributor
Email

* Sams' Club purchases do not qualify.


CMA Redemption Information


Do you belong to another Buying Group?*

 Yes

 No

Are you affiliated with a Franchise?*

 Yes

 No



ACH for Rebate Deposits

Retailer Member Cost: No Joining, Monthly, Annual, Or Out-of-Pocket Fees
Quarterly Administrative Fee (Taken Against Quarterly Rebate)
    Rebates to $500 < Quarter
    Rebates $501 > $1,000 per Quarter
    Rebates $1,001 < $2,000 per Quarter
    Rebates $2,001+ > per Quarter
    25%
    20%
    15%
    10%

Signatures

I agree and certify that I am the legal owner or authorized signer for this business and that all the information provided is true and accurate. I am legally capable of entering into this agreement and I agree to all terms and conditions as a Retailer Member of the Convenience Marketers Association. I certify all orders, reports and data including but not limited to records of sales or purchases, which I or my representatives will provide to CMA, to be true and accurate to the best of my knowledge. I authorize CMA to utilize said data for the sole purposes of negotiating and redeeming on my behalf, any and all CMA programs and promotions for each location I enroll. While enrolled with CMA, I authorize CMA to administer the tracking and payment for all CMA manufacturer programs in excess of my supplier and distributor programs. I acknowledge that any/all user permissions for programs, technology, process, or information at www.getcma.com are proprietary and provided to me and my authorized representatives on a confidential basis, solely for internal use. As such, I certify that I and my representatives will not replicate, disseminate, share, or transmit in any form, without prior written consent by Convenience Marketers Association.


  Check here to indicate that you have read and agree to the CMA Terms & Conditions


Signature of Applicant

Date

Printed Name

Company Name

Please return completed form to Psiegal@getcma.com or fax to 224-222-1025. Any questions please contact Pam Siegal at PH: 224-425-4448