DISPENSING EQUIPMENT
HANGING ALLOWANCE
North American Commercial Business
ELIGIBLE DISPENSERS
enMotion, EasyNap (vertical only), Cormatic/Ultimatic Towel, Tissue, Soap & Aire disp. Max 3000(single), RollMastr3000,
Never-Out3000, Executive3000, Carex3000, Compact, SofPull, NuRoll
CUSTOMER INFORMATION
CUSTOMER
PRINT NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE OR PROVINCE
TITLE
COUNTRY
ZIP OR POSTAL CODE
DATE
TELEPHONE
(
)
DISTRIBUTOR NAME
DISTRIBUTOR NAME (PRINT)
BUSINESS TELEPHONE NUMBER
(
ADDRESS LINE 1
CITY
)
ADDRESS LINE 2
STATE OR PROVINCE
COUNTRY
ZIP OR POSTAL CODE
MARKET SEGMENT (Check One Only)
C-Stores
Contract Cleaner
Education
Entertainment
Food Service
Food Processing
Grocery
Government
Lodging
Manufacturing
Office Buildings
Retail (Malls, Etc.)
Transportation
Other:
DISPENSER
ITEM NUMBER
DISPENSER PLACEMENTS
NUMBER OF
ALLOWANCE AMOUNT/
DISPENSERS
DISPENSER
TOTAL
By submitting this form, you confirm that this dispenser placement has been made and that the information contained herein is accurate.
1) Complete this form for each customer and attach the original dispenser proof of delivery. Incomplete forms will be returned.
2) Mail to:
Georgia-Pacific Marketing Services
P.O. Box 1447
Kennesaw, GA 30156
Questions? 1-877-377-2737 or email at customerservice@gpmarketingservices.com
Forms will be processed, provided sublease has been received.
*Funds will not be dispensed without Social Security Number. IRS Form 1099 will be issued to distributor representatives receiving $600 or more in any
calender year.
Forms are processed on a quarterly basis. All forms received within 3 days of the close of any quarter will be processed in that quarter. All forms must be
received by GP Marketing Services no later than 30 days after sale to qualify for payment.
DISTRIBUTOR REPRESENTATIVE INFORMATION
NAME (PRINT)
DISTRIBUTOR REPRESENTATIVE SIGNATURE
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE OR PROVINCE
COUNTRY
BUSINESS TELEPHONE NUMBER
HOME TELEPHONE NUMBER
(
(
)
EMAIL ADDRESS
ZIP OR POSTAL CODE
SOCIAL SECURITY NUMBER (REQUIRED)
)
GEORGIA-PACIFIC SALES REP NAME
enMotion, EasyNap, Cormatic/Ultimatic Towel, Tissue, Soap & Aire disp. Max 3000, RollMastr 3000, Never-Out 3000, Executive 3000, Carex 3000, Compact, SofPull, NuRoll
GP 12740 (02/22/2005)
GP4283
12740.DOC