Millennium Coupon Redemption Service

The Purpose of this questionnaire is to provide coupon-issuing manufactures with data on retailers who redeem coupons. All information submitted will be held strictly confidential. This coupon questionnaire must be completed and in file before payment can be issued for coupon submission:

NAME OF COMPANY/DIVISON/STORE

COMPANY/DIVISON/STORE EMAIL ADDRESS

COMPANY/DIVISION/STORE HEADQUARTERS ADDRESS

CITY

STATE

ZIP

ADDRESS TO WHICH PAYMENT SHOULD BE MADE

CITY

STATE

ZIP

ADDRESS (PHYSICAL LOCATION)

CITY

STATE

ZIP

(AREA CODE) TELEPHONE NUMBER

ATTACH LIST OF ADDRESSES & TELEPHONE NUMBERS FOR MORE THAN ONE STORE (optional)

Type of entity

Proprietorship

Partnership

Corporation

Division

NAME OF PRINCIPAL OWNERS

HOME ADDRESS

HOME PHONE NO

Entity/Entities for which coupons will be submitted:

Single Store

Total Company

Division

DATE BUSINESS STARTED/ACQUIRED

How did you obtain this business?

Purchased

Started New

Merger

COMPANY TRADE NAME OR STORE NAME (If different from item A)

FORMER STORE NAME (If Applicable)

TAX IDENTIFICATION/SOCIAL SECURITY NO

STATE OF INCORPATION (If Applicable)

BANK REFERENCE NAME:

BANK PHONE:

ADDRESS

ACCOUNT NO.:

Wholesaler Supplier(s) (if applicable)

NAME:

ADDRESS:

TELEPHONE NO:

YOUR CUSTOMER NO:

Main

Secondary 1

Secondary 2

$ ESTIMATED GROSS ANNUAL SALES:

Number of Employees:

II. Store Data

Type of store(s) (Check applicable category):

TYPE OF STORES	NUMBERS OF STORES	AVG SELLING SQ. FT PER STORE	AVERAGE CHECKOUTS PER STORE	AVERAGE WEEKLY OPEN HOURS
Food Store(s)
CONVENTIONAL SUPERMARKET
COMBINATION
WAREHOUSE
SMALL STORE
SPECIALTY
CONVENIENCE
Drug Store(s)
PHARMACY
FULL TIME
Others
Discount Store
Department Store
Liquor Store
Hardware Store
Restaurant
Military Commissary
Pet Food Dealer/Distributor
Gasoline Service Stations
Other

Note: If this form is completed for the total company and it has different divisions, and each division differs in categories stocked, please complete this page separately for each division. Division:

III. Coupon Data (For total entity submitting coupons store, company, division)

Estimate of average dollar value of coupons redeemed in one week.

Frequency of submission of coupons (Check one or insert number):

Weekly

Every Weekly

Monthly

Yearly

How are your coupons submitted?

Direct to Manufacturer(s) Yes No

Through a clearinghouse (provide name(s) and address(es):

Name		Address

Are extra-value couponing practices employed (i.e doubling or tripling coupons?)

Never

0-15 weeks per year

15-30 weeks per year

Over 30 weeks per year

Express Service Agreement

The RETAILER certifies that all coupons forwarded to Millennium Coupon Services Redemption ("MCRS") meet manufacturer's terms and conditions.

MCRS shall sort, count, submit and invoice distributing manufacturers, or their authorized agents, who have authorized MCRS to act as a clearinghouse.

The RETAILER will release and discharge the Manufacturer from any and all liability for payment to RETAILER by reason of making said payment to MCRS with the exception of pay-direct coupon submissions.

For coupons submitted to the manufacturer on a pay-direct to retailer basis, RETAILER will pay MCRS its service charge, included in the payment by the manufacturer.

RETAILER authorizes MCRS to maintain a security deposit by deducting a percentage of the amounts otherwise payable to customer as MCRS reasonably determines is necessary to cover the cost of rejected coupons or other chargebacks by a Manufacturer.

Upon Manufacturers rejection of a coupon for redemption or any other refusal to pay in a timely manner, MCRS shall charge back to RETAILER the full amount charged back by the manufacturer plus a chargeback fee equal to the 40 cents per charged back coupon and also shipping and handling cost applied by manufacturers.

In the event of a chargeback, RETAILER shall promptly pay to MCRS any unreimbursed amounts. RETAILER further agrees that he/she will be responsible to MCRS for any attorney's fees and costs incurred by MCRS in obtaining payment for chargeback.

RETAILER agrees to accept MCRS chargeback detail as documentation of manufacturer chargeback or rejection in place of physical coupon(s).

The RETAILER'S coupons will be insured by MCRS for loss from fire and theft from the time of receipt, until received by the respective manufacturers.

This agreement shall ensure to the benefit of and be binding upon the parties hereto, their successors and or assigns.

RETAILER agrees to notify MCRS within 15 days of any changes of ownership.

RETAILER submits to the jurisdiction of the state of New Jersey and to the Superior Court, Morristown, New Jersey. RETAILER irrevocably waives, to the extend permitted by law, and objection to the venue of any action brought in such court, and any claim that such action has been brought in an inconvenient forum. If RETAILER shall not have appointed an agent for service in New Jersey, RETAILER agrees it may be served by registered or certified mail, postage prepaid, mailed to its last known business address.

This agreement is in force from the date of signing and may be terminated by either side by giving 30 days notice in writing.

I agree to the terms of the Express Service Agreement of Millennium Coupon Redemption Service

Sign up

I. General Data

II. Store Data

III. Coupon Data (For total entity submitting coupons store, company, division)