2024 Rebate Distribution - Payment Method Selection

NetPlus is offering electronic rebate distribution via ACH to be received by you faster and more securely than a physical check. To receive your rebate electronically, you must complete this form which will be sent back to NetPlus when you finish and hit submit. Please note the deadline to submit is March 14th.

Please select how you would like to receive your funds this year:

Company Name

Liaison

Rebate ACH Contact

Account Id

Please select an option for rebate distribution

Opt into ACH Payment

Prefer Paper Check

Enter Bank Information

Please provide your bank information through this secure form and review the rebate contact that should receive all supporting documents via email for the rebate distributed.

The company liaison also receives these documents; if a change in liaison is necessary or you have any questions, reach out to Tori Dalio or another NetPlus team member for assistance.

tori.dalio@netplusalliance.com, 716-438-2014 ext 115

Name on Account

Sent ACH Information - New

Routing Number

Account Number

Company Rebate Contact

Sent ACH Information - Updated Contact

Is this the correct contact to receive supporting documentation for all rebate distributed, in addition to the company liaison?

YesNo

Sent ACH - Paper Check

Sent ACH - Paper Check -- Changed

Please review the rebate contact we have on file that your check should be mailed “Attention to” and should receive all supporting documents via email for the rebate distributed. The company liaison also receives these documents; if a change in liaison is necessary, please reach out to a NetPlus team member to make this update.

If changes to the information below are necessary, please answer the question accordingly and blank fields will appear to enter your updates. If you have any questions, reach out to Tori Dalio or another NetPlus team member for assistance.

tori.dalio@netplusalliance.com, 716-438-2014 ext 115

Attention To:

The information provided above is correct.

YesNo

Please complete all fields understanding this person will be updated as the company rebate contact in our system and added to all relevant communications. If this person is not listed as a current contact, a NetPlus team member may reach out to you for additional information.

First Name

Last Name

By submitting this form, you are confirming the information provided is accurate and complete, and authorizing your 2024 rebate distribution be distributed via check and mailed to the person named above.

Thank you for taking the time to review this information!

By submitting this form, you are confirming the information provided is accurate and complete, and authorizing your 2024 rebate distribution to be deposited to your bank account.

Thank you for taking the time to review this information!

Contact Information