Rebate Form

Tire Purchase Information

Date of Purchase*:

Purchased Tires*:

Upload Your Receipts*:

Upload your receipts

Fields marked with * are mandatory.

Purchase Factors

Circle All that Apply:

Age:

16-20

21-24

25-34

35-44

45-54

55-64

65+

Gender:

Why did you purchase the tire(s)?

Damaged Tire

Worn Out

Did Not Like

What attributes were IMPORTANT factors when purchasing your tires?

Tire Life

Handling

Fuel Efficiency

Retailer Tire

Tire Brand

Tire Price

Rebate

Why did you choose Falken?

Performance

Appearance

Original Equipment

Price

Brand Reputation

How many vehicles are in your household?

Recommended by

Yes, please send me future coupons and offers from Falken.

Customer Information

Visa Prepaid Card

It may take 8-10 weeks for your Visa prepaid card to arrive.

First Name *

Last Name *

Phone Number *

Email Address *

Address 1 *

Address 2

City *

State/Province *

Zip Code *

Would you like to receive email updates on your rebate status?

Yes, please send me email updates.

Fields marked with * are mandatory.

Refund Request Form

Rebate Form

Tire Purchase Information

Purchase Factors

Circle All that Apply:

Customer Information

Visa Prepaid Card

Thank you for submitting your refund request.

Your refund number is for

You will receive a rebate of ${0}. Your card will be delivered to you in {1}.