Name* First Last Email* Contact Title*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code The following “Community Reward” offer(s) may be made through DFCA to its members as our way of helping teens continue to make the right choice:*Members may redeem this offer by:* Simply showing Valid photo ID Club Card - Issued by DFCA at time of membership Presenting a printed coupon or voucher with Valid Club Card (vouchers must be produced by business and sent to applicable school) Additional Notes, Details, or Restrictions:By signing below, I confirm that: 1. I have the authority to present this offer as detailed on this agreement 2. I am not relying upon any promise, or representation of return other than as previously stated. 3. The above reward offer will remain in place until a written request is made, upon which time any parties involved will comply with the request within two calendar weeks. Authorization: Type your First and Last Name as Listed Above in the box below to confirm.Name* First Last
