R5000-HD Referral Rebate Form

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Refer a friend and earn $50.00!
If you already own or have purchased an R5000-HD system, you can now earn cash by telling your friends (family, co-workers, etc.) about it. For every sale produced by one of your referrals, you will receive $50.00 cash. There is no limit to the number of referrals you can submit (fill out this form separately each time). Please read the terms and conditions, below, for details and eligibility requirements.

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1. Order information

Every buyer is supplied an order number when they make a purchase.

Order number:*

2. Your Information

Please fill in your information accurately. Payment will be made to this person and mailed to this address.

Name: *

Address & Street:*

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City:*

State/Province:*

Zip/Postal Code: *

Country: *

Email: *

Phone:

3. Terms & Conditions

Valid only for orders placed while this offer is effect (starting June 14, 2007 until withdrawn). Claimant must have previously purchased an R5000-HD modification from Nextcom, LLC. Claimant and purchaser may not be the same person, in other words, you cannot refer yourself. The information submitted via this form will be used to verify your eligibility. We may require further information, so please provide a valid and current contact method. Not valid if order is returned or cancelled. Allow 4-6 weeks for processing.

By selecting "Agree" you state that you have read and agree with the above terms and conditions. Selecting "Disagree" will void this form and any information submitted.

Confirm:*

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