Gasoline Coupon Gasoline Coupon Gasoline Coupon

							Gasoline Coupon                                         Gasoline Coupon                                          Gasoline Coupon
          2011 PMCA of Kansas                                     2011 PMCA of Kansas                                      2011 PMCA of Kansas
    Holiday Highways Safety Program                         Holiday Highways Safety Program                          Holiday Highways Safety Program

Donor Information                                       Donor Information                                        Donor Information
To be completed by participating Marketer or Retailer   To be completed by participating Marketer orr Retailer   To be completed by participating Marketer or Retailer
and returned to PMCA by December 9, 2011.               and returned to PMCA by December 9, 2011.                and returned to PMCA by December 9, 2011.

Name of Company:                                        Name of Company:                                         Name of Company:



Location Address:                                       Location Address:                                        Location Address:



City:                              County:              City:                               County:              City:                               County:



State:                             Zip:                 State:                              Zip:                 State:                              Zip:



Signature of Owner/Operator Donating Coupon:            Signature of Owner/Operator Donating Coupon:             Signature of Owner/Operator Donating Coupon:



Trooper Information                                     Trooper Information                                      Trooper Information
To be completed by trooper upon redeeming this coupon   To be completed by trooper upon redeeming this           To be completed by trooper upon redeeming this
between Dec. 24. 2011 and Jan. 1, 2012.                 coupon between Dec. 24. 2011 and Jan. 1, 2012.           coupon between Dec. 24. 2011 and Jan. 1, 2012.

Name of Trooper:                                        Name of Trooper:                                         Name of Trooper:



Car #                        Date Redeemed              Car #                        Date Redeemed               Car #                        Date Redeemed


         This coupon valid between                               This coupon valid between                                This coupon valid between
 December 24, 2011 and January 1, 2012 for               December 24, 2011 and January 1, 2012 for                December 24, 2011 and January 1, 2012 for
  gasoline placed in the fuel tank of marked              gasoline placed in the fuel tank of marked               gasoline placed in the fuel tank of marked
    Kansas Highway Patrol vehicles only.                    Kansas Highway Patrol vehicles only.                     Kansas Highway Patrol vehicles only.


Please return this                                      Please return this                                       Please return this
coupon to PMCA                                          coupon to PMCA                                           coupon to PMCA
by Dec. 9, 2011.                                        by Dec. 9, 2011.                                         by Dec. 9, 2011.