Subway Certificate Format Form – Fill Out and Use This PDF

Purchaser Information

New Client

Reorder

Order Date: _____ / _____ / ______ PO#: _______________________

Name: ____________________________________________________

Company Name: ___________________________________________

Address: __________________________________________________

Address: __________________________________________________

City: ___________________ State: _____________ Zip: ____________

Phone: __________________ E-Mail: ___________________________

Federal Tax ID/BN# (required for fundraisers): _______________________________

Referring SUBWAY Store # ____________

Ordering Information

Min. Order: 10 Cards | Min. Card Load: $5 | Min. Total Order: $250 | Max. Card Load: $100

BULK ORDER DISCOUNT - Save 2% on any order of $5,000 or more.* FUNDRAISER BULK DISCOUNT - Save 6% on any order of $500 or more.* Must provide a valid 501(c)(3) Tax Exempt #________________

*Not applicable on purchases made with a credit card

•When ordering multiple currencies, please submit separate order forms for each currency.

Cards will be loaded with either U.S. or Canadian Dollars however, cards can be used in either country.

The Point-of-Sale system will automatically convert currency at the time of transaction based on established exchange rates. **Bilingual Cards are intended for use in Canada.

Specify Funds To Be Loaded		$US	$CANADA
Card	United States (English)	Card Load Denom.	Line Total
Quantity	Canada (English/French)	($5 - $100)	(Quantity x Denom.)

Pack		Envelope Item Description	Price Per Pack of 50	Line Total
Quantity				(Quantity x Price)
		U.S. Green Bow Envelope	$4.00
		Canada Red Bow Envelope	$4.00
		SELECT SHIPPING OPTION BELOW
	Ground Delivery (1-6 Days)		FREE	FREE
		Next Business Day	Under 250 Cards	$60.00
Orders must be received by 11:00 am Eastern
			251 - 2500 Cards	$150.00
for same day shipping. Applies to shipping only within
		continental United States
			2501 - 5000 Cards	$250.00
		Shipping Information	Card Total
Allow 2-3 days for order processing prior to shipping.
Shipping is available to one address only.			Less Discount
Orders are not processed until payment is conmed.
*Overnight orders must be receieved no later than 11:00 am			Order Total
Eastern for order to be processed for delivery.

Authorized Signature

Signature _____________________________ Title ________________

Company __________________________ Date ____ / ____ / _______

Terms & Conditions

By signing the above you agree to purchase the cards speciied in this order. SUBWAY® Cards are issued by Value Pay Services

LLC and may only be used for purchases at participating SUBWAY® restaurants. Unless the Card is registered online at www.mysubwaycard.com, remaining balances on lost, stolen or damaged Cards cannot be replaced or refunded.

Questions? Please contact Value Pay Services (VPS) at 786-270-1273

Shipping Information

Same as Customer Information Name: ____________________________________________________

Company Name: ___________________________________________

Address: __________________________________________________

Address: __________________________________________________

City: ___________________ State: _____________ Zip: ____________

Phone: __________________ E-Mail: ___________________________

Payment Information

Credit Card Payment*

* (Limit $5,000. For orders over this amount please use another payment method.)

VISA

MASTERCARD

AMEX

DISCOVER

Name on Card: _____________________________________________

Address: __________________________________________________

Address: __________________________________________________

City: ___________________ State: _____________ Zip: ____________

Phone: __________________ E-Mail: ___________________________

Card #: ____________________________________________________

Expiration #: _____ / ______Security #: _____________

Authorized Signature: _______________________________________

ACH	AVAILABLE ONLY IN THE U.S.
* (Fax to 305.670.9586)

Account #: _____________________ ABA#: _____________________

Name on Account: __________________________________________

Authorized Signature: _______________________________________

I hearby authorize VPS LLC to initiate a debit transaction for the order total amount from the account speciove.

FAF

Program Description: ________________________________________

Market #: __________________ Program Timing: _________________

COMPANY CHECK or MONEY ORDER

Make Checks Payable to: Value Pay Services

Mail Order Form with payment to:

SUBWAY CARD PROGRAM

Value Pay Services LLC | ATTN: Corporate Sales 9200 S. Dadeland Blvd. Suite 705 | Miami, FL 33156

* Orders paid by check will not be processed until funds have cleared the bank (7-10 days)

All orders are NOT processed until payment is conmed. All bulk order Card sales are . No return and no refunds. Cards

are shipped inactive as a safeguard against unauthorized use in the event cards are lost or stolen. Buyer is required to submit an activation request form to VPS to conm delivery of order so that cards can be activated prior to use. Card activation takes

24-48 business hours from VPS’ receipt of your activation form. Card balances do not expire or decline with non-use nor are there any fees or service charges associated with dormancy. SUBWAY® Cards can be used in the United States, Canada, Puerto Rico, Guam and Saipan at this time.

When, where and how will these cards be used or distributed and will there be any promotional or marketing materials created?

Any materials created by you which feature the SUBWAY® logos, Cards, Menu Items, or other proprietary images must be submitted to VPS for approval prior to their use or distribution. Submit to: subwayecardorders@ipcoop.com

Internal VPS use only 501(c)(3) Tax Exempt # Verition IPC: _________________________