CLAIM FOR: ❏ Model Home Credit ❏ Display Floor Credit
DISTRIBUTOR
Name: _____________________________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________
City: __________________________________________________________________ State:___________________________ ZIP: _______________________________
Telephone:_____________________________________________________________
RETAILER
Name: _____________________________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________
City: __________________________________________________________________ State:___________________________ ZIP: _______________________________
Telephone:_____________________________________________________________
TRACT OR DEVELOPMENT
Name: _____________________________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________
City: __________________________________________________________________ State:___________________________ ZIP: _______________________________
Telephone:_____________________________________________________________
Product Used: __________________________________________________________ Number of Models:___________________________________________________
Contact: ____________________________________________________________________________________________________________________________________
BUILDER
Name: _____________________________________________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________
City: __________________________________________________________________ State:___________________________ ZIP: _______________________________
Telephone:_____________________________________________________________
Date Material Installed:_____________ Total Sq. Footage Potential:____________ No. of Homes To Be Built:_______________________________________________
A BR-111
™
Display Must Be on the Premises. Display Type:___________________________________________________________________________________________
B R - 111
™
Item #:____________________________ Product Name:_________________________________________________ Species: ____________________________
CONTRIBUTION SYSTEM MINIMUM
Maximum BR-111
™
BR-111
™
Sq. Ft. BR-111
™
Distributor Dealer
1. Display Floor Opportunities 200 25% 25% 50%
2. Model Home Flooring Opportunities 400 25% 25% 50%
TO CALCULATE CREDIT REQUEST:
A. Enter sq.ft. invoiced to retailer/contractor/builder for showroom floor.
1
) __________________ __________________________________________________
B. Enter distributor cost/sq.ft.
2
) $ __________________
Distributor Sales Manager Signature
C. Multiply line one (sq.ft.) & line two (price/sq.ft.) and enter here.
3
) $ __________________ __________________________________________________
D. Multiply line three by 25% to determine applicable credit.
4
) $ __________________
BR -111
™
Approval
_____________________ Date:_____________________________________________
This form must be COMPLETELY filled out to receive credit. Incomplete forms WILL BE RETURNED. Copy of distributor invoice MUST accompany this form.
MAIL TO: BR-111
™
Attention – Credit Department
IMPORTANT: All Display and Model Home Floors Must Be Pre-Approved by BR-111
™
.
8/30/04
108
12800 NW 107th Court
•
Medley, Florida 33178
•
(800) 525-BR111(2711)
•
Fax (800) 577-2711
•
www.br111.com
SS
SS
HH
HH
OO
OO
WW
WW
RR
RR
OO
OO
OO
OO
MM
MM
&&
&&
MM
MM
OO
OO
DD
DD
EE
EE
LL
LL
HH
HH
OO
OO
MM
MM
EE
EE
FF
FF
LL
LL
OO
OO
OO
OO
RR
RR
II
II
NN
NN
GG
GG
PP
PP
RR
RR
OO
OO
GG
GG
RR
RR
AA
AA
MM
MM
Debit #______________ Chargeback #______________
