Retailer Co-op Ad Program Reimbursement Form
Retailer Information
Retailer Name
Store ID/Number
Address
City
State
ZIP Code
Contact Information
Contact Person
Phone Number
Email
Ad Program Details
Type of Ad/Promotion
Start Date
End Date
Description
Reimbursement Details
Expense Description
Vendor
Invoice #
Invoice Date
Amount
Total Amount
Notes/Comments
Certification
Signature
Date