Coupon Request

Dealer Information

Dealer name

City

State

Employee Information

Employee first name

Employee last name

Customer Information

Customer first name

Customer last name

Customer ranch name

Mailing address

City

State

ZIP code

Phone #

Product Information

Product purchased Ultramin Elite™ Other Payback Mineral

Date of purchase

Tons purchased

Upload receipt/invoice

Drop files here or

Upload media

Max file 35MB size per form. Larger file sizes take longer to upload. Acceptable file formats include: PDF, JPGs, PNGs, BMP, JPEGs.

All image files must be selected from the same location and added to the uploader at the same time using the CRTL or SHIFT key. Please do not close window until fully uploaded.

Coupon will be mailed within one week of form submission. Please let them know they will receive the coupon 2-3 weeks after purchase in the mail from CHS animal nutrition.