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Bulk Gift Cards: Customer Intake Form

Is this account for a business or an individual customer?

Personal Information

First Name

Middle Name

Last Name

Name Suffix

Date of Birth

Phone Number

Street/Mailing Address

Apt., Suite.

City

State

ZIP

Occupation

Email

Additional Information

Projected annual purchase amount in US dollars

Intended use of Gift Cards

Are these cards intended for use outside the US?

Yes No

Will the funds used to purchase these cards come from federal, state, or local government funding sources?

Yes No

Any additional notes

Document Upload

File size cannot exceed 8MB.
Total number of attachments cannot exceed 8.
Accepted file types: pdf doc docx jpg jpeg png csv.

Company Information

Company Name

Street/Mailing Address

Apt., Suite.

City

State

ZIP

Company Phone Number

Business License Number

Tax ID Number

Type of Business

Number of Employees

Products and Services Offered

Website

Contact Information

First Name

Middle Name

Last Name

Name Suffix

Date of Birth

Phone Number

Ext.

Email

Job Title

Additional Information

Projected annual purchase amount in US dollars

Intended use of Gift Cards

Will the funds used to purchase these cards come from federal, state, or local government funding sources?

Yes No

Will you be selling Walgreens Gift Cards to other businesses?

Yes No

Will Walgreens be entered into any government vendor or contractor database?

Yes No

Any additional notes

Document Upload

File size cannot exceed 8MB.
Total number of attachments cannot exceed 8.
Accepted file types: pdf doc docx jpg jpeg png csv.

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