H-E-B Promotional Coupon Contract
Instructions for this form can be found here.
(a) Retailer Offer #:
(b) Description to appear on coupon:
(c) Size or range of size:

(d) List the Manufacturers ID # (MIN):

(e) UPC/Item Code of Buy Item:
(f) Additional instructions:
 (g) Value of Coupon:
 
Cannot Exceed $10.00
(g1) Max Value if "FREE":
 
Cannot Exceed $10.00
(h) List All Family Codes:
       
Do all New Items, Bonus Packs and Special Packs associated
with this coupon offer have family codes assigned?

(i) Retailer Share of Value:
 		 (j) Mfr./Broker Share of Value:
(k) MFR HANDLING ALLOWANCE: CHECK APPROPRIATE BOX
Type 8 Mfr handling:  $0.10
Type 9 Coupon handling:  $0.08 
Manufacturer Information
(l) Mfr. Offer Code #:
 
 For all Type 9		 (m) Mfr./Broker Contact:
(n) Phone #:
 
We authorize HEB the right to use coupons on the Internet unless checked below.
No, do not use coupon on the Internet.
(o) MUST INCLUDE ALL Item codes or UPCs included in offer.
Check Boxes if Item Codes Contain Links.
Primary Item Codes:
       
All Other Codes or UPCs:
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
(p) DISTRIBUTION METHOD CHECK AD DATE
 Wednesday Pre-Print
 Sunday Drugstore
 Month Long Tab
 Grand Opening
 Showtime Events - Demos
 Other: 
 (q) Issue Date:  
 (r) Expiration Date:    
 (s) SA Food/Drug SA WEST  AUSTIN 
BORDER  NORTH 
GULF  ALL 
 Houston Food/Drug URBAN  NORTH 
SOUTH  EAST 
ALL   
 (s) Central Market  
 (y) In-Pump Ad   
UPC
Internal Use Only
(t) Coupon Billing Information
Must be filled out for all coupons.
 (1) Coupon Remit to:
 
 (2) Coupon Address:
 
 (3) City/State/Zip:
     
 (4) Clearing House Mfr #:
 (5) HEB Internal Account #:
 (6) Share of Value of Coupon:
 (1) Coupon Remit to:
 
 (2) Coupon Address:
 (3) City/State/Zip:
  
 (4) Clearing House Mfr #:
 (5) HEB Internal Account #:
 (6) Share of Value of Coupon:
 (1) Coupon Remit to:
 
 (2) Coupon Address:
 (3) City/State/Zip:
  
 (4) Clearing House Mfr #:
 (5) HEB Internal Account #:
 (6) Share of Value of Coupon:
 (1) Coupon Remit to:
 
 (2) Coupon Address:
 (3) City/State/Zip:
  
 (4) Clearing House Mfr #:
 (5) HEB Internal Account #:
 (6) Share of Value of Coupon:
 (1) Coupon Remit to:
 
 (2) Coupon Address:
 (3) City/State/Zip:
  
 (4) Clearing House Mfr #:
 (5) HEB Internal Account #:
 (6) Share of Value of Coupon:
(u) Vendor/Broker Email:
  
Vendor Name:
Vendor Phone:
Vendor Address:
City/State/Zip:
  
(v) BDM/Buyer Merchandiser Email:
  
BDM/Buyer Merchandiser Name:
BDM/Buyer Merchandiser Number:
 
BDM Notification Only Email:
 
(w) Ad Administer Name/Extension (if Applicable):
Corporate Pricing Extension:
Store Receivables Authorization/Extension:
(x) Date:
(mm/dd/yyyy)
Vendor agrees that it shall honor all coupons from the date of issuance
up to 90 days following the expiration date listed on the coupon. In-Ad
coupons will be destroyed 60 days from receipt date.
By clicking on "I AGREE", I (1) consent to the Texas Uniform Electronic Transaction Act ("UETA") as codified in Chapter 43 in the Texas Business and Commerce Act and to related Federal laws that apply to all electronic records or signatures, and (2) agree that I am creating a valid electronic signature thereby agreeing on behalf of myself and any party I represent to be bound by the terms and conditions of this Coupon Release Form.

REVISED: 02/07/2007


I do not agree to these terms.