Rockstar Xdurance – Spring 2019 College & University Promo

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Please Select Your Region *

Please enter the number of incremental cases sold in below. *

Enter a numeric value only.

Please choose a prize based upon the corresponding qualification level below! *

Customer Information

College Name *

Account Name *

COF # *

Customer Name *

Enter the name of the main contact

Customer Address *

Note - we are unable to ship to P.O. Boxes

Customer City *

Customer State *

Customer Zip Code *

Customer Phone *

Customer Email

Sales Rep. Information

Sales Rep. Name *

Sales Rep. Address *

Note - we are unable to ship to P.O. Boxes

Sales Rep. City *

Sales Rep. State *

Sales Rep. Zip Code *

Sales Rep. Phone *

Sales Rep. Email *

Sales Rep. Affiliation Rockstar

If Rockstar, check the box below for signature authorization.

Rockstar

Sales Rep. Affiliation Pepsi

If Pepsi, check the box below for signature authorization.

Pepsi

Order Confirmation & Fulfillment

Please allow 3 weeks for normal delivery.

Ship to: *

Notes

For Additional Information & Questions...

Please contact Carleigh Buehler: Carleigh@Rockstarenergy.com 310.704.1817

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