Welcome to

Rebate Headquarters Online Mail-In Claim Form

Use this form to streamline and prioritize your request through the administrative process.

ONCE COMPLETED YOU MUST PRINT OUT THE CLAIM FORM AND MAIL IT IN WITH THE REQUIRED DOCUMENTS. YOUR REQUEST IS NOT COMPLETE UNTIL YOU MAIL YOUR COMPLETED ONLINE CLAIM FORM AND ALL REQUIRED DOCUMENTATION TO REBATE HEADQUARTERS.

Remember to make backup copies of everything you mail in for future reference.

NOTE: The name you enter below MUST match the name on the invoice when applicable. Please refer to the program's terms and conditions. To view Goodyear privacy policy, please Click Here.

All required fields must be entered correctly
First 4 digits of your Goodyear Credit Card Account Number:
*Invoice Number:		Invoice number is required
*Purchase Date:		Purchase date is not in Event Range Purchase date cannot be in future
Store NonSig # (optional):
*Based on the purchase date, select the Mail-in rebate you're applying for:	8/15/2010 -9/11/2010 Get Up To $160 Rebate	Please choose a rebate Un-select and reselect rebate to populate tirelines.
*Tireline:		Please choose a Tireline
*First Name:		First Name is required
*Last Name:		Last Name is required
*Street Address:		Address is required
*City:		City is required
*State:	Choose a state... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	State is required
*Zip Code:		Zip is required
*Daytime Phone: format: 123-456-7890		Daytime Phone is required Wrong Format
*Email:		Email is required Email fields don't match Invalid email format
*Re-Type Email:

To date: in rebates have been donated to Support Our Troops! You can elect to donate all or part of your rebate to Support Our Troops®, a non-profit group dedicated to assisting the men and women in our armed services and their families. Your donation is tax deductible. Click here to learn more.

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