REWARDS CENTRAL MAIL IN SUBMISSION FORM

REWARDS CENTRAL MAIL IN SUBMISSION FORM
COMPILE the following documents to complete your submission.
SELECT YOUR ACUVUE® BRAND
Please mark the left (L) eye and right (R) eye brand corresponding to your purchase.
This submission form (completed)
Copy of your receipt showing Eye Care Professional's name,
ACUVUE® Brand purchased, quantity purchased, purchase date
and purchase price. Please ensure all information is legible.
ACUVUE® VITA™
ACUVUE OASYS® 2-Week
ACUVUE OASYS® 2-Week for ASTIGMATISM
MAIL all documents to:
HelloWorld, Inc.
PO Box 5085
Kalamazoo MI 49003-5085
ACUVUE OASYS® 2-Week for PRESBYOPIA
ACUVUE OASYS® 1-Week Overnight
ACUVUE OASYS® 1-Day with HYDRALUXE™ Technology
By submitting my information, I agree that Johnson & Johnson
Vision Care, Inc., may use it to evaluate my Rewards Submission
and to contact me about this program, and that it will be governed
by the Johnson & Johnson Vision Care, Inc., Privacy Policy. I have
read the Full Terms and Conditions. Reward requests must be
received within 30 days of purchase.
1-DAY ACUVUE® MOIST for ASTIGMATISM
CONTACT INFORMATION
1-DAY ACUVUE® DEFINE®
1-DAY ACUVUE® MOIST
1-DAY ACUVUE® MOIST Brand MULTIFOCAL
1-DAY ACUVUE® TruEye®
All fields required. Please print clearly.
FIRST NAME
SELECT THE QUANTITY PURCHASED
LAST NAME
Please mark the left (L) eye and right (R) eye box corresponding to your purchase.
1 Box (12 Lenses per Box)
EMAIL ADDRESS
1 Box (24 Lenses per box)
1 Box (90 Lenses per Box)
MOBILE PHONE
2 Boxes (6 Lenses per box)
2 Boxes (12 Lenses per box)
ADDRESS (NO P.O. BOXES, PLEASE.)
2 Boxes (24 Lenses per box)
2 Boxes (54 Lenses per box)
CITY
STATE
ZIP CODE
2 Boxes (90 Lenses per box)
3 Boxes (30 Lenses per Box)
BIRTH DATE (MM/DD/YYYY)
PURCHASE DETAILS
4 Boxes (6 Lenses per box)
4 Boxes (12 Lenses per box)
4 Boxes (90 Lenses per box)
REWARDS CODE
(From the Promotional Page provided by your Eye Care Professional)
6 Boxes (30 Lenses per box)
8 Boxes (6 Lenses per box)
8 Boxes (90 Lenses per box)
EYE CARE PROFESSIONAL (First and Last Name)
12 Boxes (30 Lenses per box)
24 Boxes (30 Lenses per box)
NAME ON PRESCRIPTION
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Available Rewards
ACUVUE OASYS® Brand
1-Day with HydraLuxe™ Technology
1-DAY ACUVUE® MOIST Brand
Contact Lenses
1-DAY ACUVUE® MOIST Brand
for ASTIGMATISM
1-DAY ACUVUE® MOIST Brand
MULTIFOCAL
1-DAY ACUVUE® DEFINE® Brand
Contact Lenses
1-DAY ACUVUE® TruEye® Brand
Contact Lenses
ACUVUE OASYS® Brand
1-Week for Overnight Use*
(*Available as Annual Supply Only)
ACUVUE® VITA™
Brand Contact Lenses
ACUVUE OASYS® Brand
Contact Lenses 2-Week
ACUVUE OASYS® Brand
2-Week for ASTIGMATISM
ACUVUE OASYS® Brand
2-Week for PRESBYOPIA
80
$
ANNUAL SUPPLY
35 10
$
$
6 MONTH SUPPLY
40
$
ANNUAL SUPPLY
20
$
ANNUAL SUPPLY
35
$
ANNUAL SUPPLY
3 MONTH SUPPLY
10
$
6 MONTH SUPPLY
10
$
6 MONTH SUPPLY
10
$
6 MONTH SUPPLY
TERMS & CONDITIONS. Purchases of ACUVUE OASYS® Family,1-DAY ACUVUE® MOIST Family, 1-DAY ACUVUE® TruEye®, ACUVUE® VITA™ and 1-DAY ACUVUE® DEFINE® must be
made in-office or in-store between June 30, 2016 and Dec 31, 2016.** Reward requests must be received within 30 days of purchase***. Product purchase must be made within 90
days after contact lens fit/exam. Limit one reward per customer, per offer, per yearly eye exam visit. This offer is not valid in combination with any other product offer including
Money Back Guarantee. Offer valid for U.S. residents only. Offer not valid where prohibited by law. Allow 14 days for delivery. No P.O. boxes, only street or rural addresses are
acceptable. Fraudulent submissions could result in federal prosecution under the U.S. Mail Fraud Statutes (18 U.S. Code Section 1341 and 1342). Not responsible for lost, late or
undelivered responses.
ACUVUE® Rewards are only valid on in-office purchases and purchases made at participating retail locations. Rewards are not valid for internet purchases or purchases made at
Costco® Optical, Sam’s Club® Optical, BJ’s® Optical, Walmart® Optical or Target® Optical, but other offers may be available for ACUVUE® Brand purchases at these retailers.
NOTICE TO CONSUMERS: If you are personally filing a claim for reimbursement from a third-party payer (e.g., insurance company, employer group, etc.) for the purchase of this
product, your claim must be based upon your payment less the amount of this reward. If your doctor is filing the claim, you must notify the doctor’s office of the need to deduct this
rebate amount from the purchase price used in calculating the claim.
**Rewards are in the form of an ACUVUE® Brand Visa Prepaid Card. Card is issued by The Bancorp Bank, Member FDIC, pursuant to a license from Visa U.S.A. Inc.
***Johnson & Johnson Vision Care, Inc., reserves the right to cancel this rewards program at any time without notice.
ACUVUE®, ACUVUE OASYS®, 1-DAY ACUVUE® MOIST, 1-DAY ACUVUE® TruEye®, ACUVUE® VITA™, 1-DAY ACUVUE® DEFINE® are trademarks of Johnson & Johnson Vision Care,
Inc.
©Johnson & Johnson Vision Care, Inc. 2016. The third-party trademarks used herein are trademarks of their respective owners.
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