eScrip supporter registration form

I have read the eScrip program information and authorize ESI to charge an annual $10 registration fee to the first available bank card listed below upon receipt of my registration and annually thereafter (or enclose a check to ESI for payment). If I choose to support more than one group, I understand that I will be charged an annual $5 fee for each additional group (maximum of 3 groups). I understand that this is a non-refundable fee and that I may cancel my participation at any time.I understand that ESI reserves the right to discontinue or alter the terms of this program, including the participating merchants, the contribution percentages, and the registered card types that are accepted by merchants, at any time without prior notice.

Signature

Date

Register all household cards on this form.

Merchant Name

Please list grocery loyalty cards below (refer to eScrip merchant list)
If there is more than one Safeway Club Card in your household, register both cards.

1. – –

2. – –

• Use of your Safeway Club Card is required at checkout to automatically track the contribution to your organization.
• Apply and receive a free Safeway Club Card at any Safeway location.

Card Type Card Number Exp. Date

Below, please list Chevron card you wish to register.
Please register personal cards only, commercial and corporate cards are excluded. Call 1-800-FREE-APP to apply.

- - - -

Below, please list Visa/Mastercard debit card you wish to register.

1. Debit -

The other ATM/debit card you wish to register.

1. ATM -

Below, please list the bank card numbers you wish to register
(e.g., VISA, MC, AmEx, Disc).

1. VISA -

2. MC -

3. AmEx -

4. Disc -

ESI has made a firm commitment to protect the privacy of all customer information. ESI will not sell or rent any personally identifying information about eScrip participants to any third parties.

eScrip Program Information
1. The Electronic Scrip (eScrip) program is intended to benefit schools and organizations that support children and children’s programs. An organization must be enrolled with ESI in order to receive donations from participating merchants in connection with the program.
2. Once your designated organization is enrolled, you can apply to participate in the program by submitting a completed card registration form. You will be charged an annual fee of $10 to participate in the eScrip program in support of one organization. There is an annual $5 fee for each additional organization (up to 3 maximum). ESI will split your donation amount equally between your multiple designations and provide complete reporting of each. The applicable annual fee is automatically charged to the first available bankcard listed on your registration form, or you may send a check with your registration form. This is a non-refundable fee and participation may be cancelled at any time.
3. After processing your registered cards for enrollment, a percentage of your qualified purchases, as determined by participating merchants, is donated to your designated organization.
4. ESI will track all purchases made with registered cards from participating merchants and distribute the accumulated donations to the designated organization(s) on a monthly basis.
5. Your organization designation may be changed once a year by contacting ESI.
6. Your registered card numbers will be kept confidential by ESI and will be disclosed by ESI only to participating merchants, eScrip program processors, or as otherwise required by law.
7. ESI has made a firm commitment to protect the privacy of all customer information. ESI will not sell or rent any personally identifying information about eScrip participants to any third parties. Purchase information shared with eScrip merchants is for the sole purpose of auditing the eScrip program. Purchase activity is not shared between eScrip merchants. By participating in the eScrip program, you are authorizing ESI: (a) to use information relating to your registered card transactions for the limited purposes of (1) processing the contributions that are to be distributed to your designated organization and (2) providing transaction reports to your designated organization and the participating merchants; and (b) to allow ESI to offer products, specials, and services that may be of interest to you.
8. By registering your cards, you understand that your designated organization will receive the following two reporting figures:
1) Total purchase amount made with registered cards.
2) Total donations paid by merchants. Your organization will not receive any card I.D. numbers or purchase details.
9. ESI reserves the right to discontinue or alter the terms of this program, including the participating merchants, the contribution percentages, and the registered card types that are accepted by merchants, at any time without prior notice.

ESI MAKES NO PROMISES, REPRESENTATIONS OR WARRANTIES, EITHER EXPRESS, IMPLIED, STATUTORY OR OTHERWISE AND ESI SPECIFICALLY DISCLAIMS ALL IMPLIED WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT AND FITNESS FOR A PARTICULAR PURPOSE. IN NO EVENT SHALL ESI HAVE ANY LIABILITY FOR ANY DIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES, HOWEVER CAUSED AND UNDER THEORY OF LIABILITY, INCLUDING NEGLIGENCE, AND WHETHER OR NOT ESI HAS BEEN ADVISED OF POSSIBILITY OF SUCH DAMAGE.