I certify that I have received these MediBucks in Medique Brand products that I have purchased through an authorized distributor and that I am eligible to redeem these MediBucks as stated in the program information.

Distributor Name:
Number of MediBucks being redeemed:
(you must redeem at least 500 points at this time. 500 points = $5.00)


Please Send my Gift Certificate To:
Name
Title
Company
Address
Address 2
City
State Zip
Country
Phone Ext.
Fax
E-Mail