Facility Information
Facility Name:
Parent Organization:
Facility Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Information
Contact Function/Title:
Name:
First Name
Last Name
Phone Number:
-
Area Code
Phone Number
Email Address:
example@example.com
Tax ID:
Shipping Information:
Facility Name:
Facility Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Purchase/Redemption Information:
Welch Allyn Rep Name:
Distributor Company:
Distributor Rep Name:
Distributor Rep Email:
Distributor PO #:
Redemption Options:
To receive your rebate...
Enter the number of qualifying Q-Stress Cardiac Stress Testing System(s) purchased with a treadmill (Eligible part numbers: QS6-ATTD1, QS6-MLTC1):
*
Enter the number of qualifying Q-Stress cart-only purchases (Eligible part numbers: QS6-ATTDX, QS6-MLTCX):
Upload Invoice(s) and a W-9 if your rebate amount is above $600.
*
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