Promotion Redemption Form

Thank you for taking advantage of our promotion.

Please fill out and submit the form below. Fields marked with an asterisk (*) are required.

* Name:

* Title/Function:

* Institution:

* Business Address:

Building/Room/Lab:

* City:

* State/Province:

* Postal Code:

* Business Telephone:

* Your E-mail Address:

Shipping Address (if different from above)

Ship to Address Line 1: (no PO Boxes)
Ship to Address Line 2:
City:
State / Province:
Postal Code:

* Primary Discipline:

Promotion Code:
(if applicable)

* Name of Promotion / Offer:

* I purchased:

(name of product(s) and number of cases)

* Distributor from
which I purchased:

PO Number:

(if you do not have a PO number please complete the Case and Lot Number field below.)

Case and Lot Number from each purchased case:

(these numbers are printed on the label affixed to the outer case of most products.)

Please send me
my free good(s):

(include catalog numbers if applicable)

Comments:

Note:

Please email proof of purchase to lspromo@corning.com or fax to 987-422-2478 within the U.S. or 001-978-422-2478 outside the U.S.

Please allow 2-3 weeks for your item(s) to arrive.

> Redeem Offer

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