Trade-In & Trade-Up Rebate Claim Form

Thank you for your interest in the Trade-In & Trade-Up rebate promotion. Please fill out the below form to initiate the administration of your rebate claim. Upon processing, you will receive an approval letter, claim number and shipping label(s) via email from Panasonic. Rebate checks will be mailed upon receipt and processing of the used equipment at the Panasonic recycling facility.
All fields with an * are required.
Please complete the missing fields highlighted in red below.
Email entered is not a valid email address.
Email addresses entered do not match.
The phone number entered is not in the correct format. Please use (XXX) XXX-XXXX.
The phone number extension must be numeric.
The ZIP code must be a valid, 5-digit U.S. zip code.
Please verify that you accept the terms and conditions of this offer.
  First Name *
  Last Name *
  Email address *
  Confirm email address *
  Phone * ext.
  Company Name *
  Company Address Line 1 * 
  Company Address Line 2
  City *
  State *
  ZIP Code *
Existing Equipment Being Replaced
  Manufacturer *
  Model # *
  Serial # *
  Weight *
Panasonic Replacement Equipment
  Model # *
  Serial # *
  Reseller *
  Purchase Date *
  I agree to all terms and conditions.