KickBack Blitz

Store Number:*
Select Prize Amount:*
- 200
- 400
- 600
- 800
- 1000
- 1500
Customer Name:*
First Last
Phone Number:*
Enter customers phone number.
KickBack Card Number:*
You must enter a valid Kickback card number. Please double check the number so there are no issues in rewarding the customers winnings.