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TOM THUMB REWARD CARD APPLICATION

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					   TOM THUMB REWARD CARD APPLICATION                                                                                                   TAPE CHECK HERE
   PLEASE COMPLETE AND SIGN THIS APPLICATION. PRINT CLEARLY IN BLACK OR BLUE INK.


   NEW CARD APPLICATION
        New Member                           New Member with
        (please complete                     Tom Thumb SMARTCHECK
        Section 1 only)                      (please complete Sections 1 and 2)                  INTERNAL USE
                                                                                                  Place Card #
   CHANGES TO EXISTING CARD ACCOUNT                                                               Sticker Here

   Existing Reward Card Number (required)

        Replacement Card                      Name/Address /Phone Update                     Add Tom Thumb
        (please complete Section 1)           (please complete Section 1)
                                                                                             SMARTCHECK
                                                                                             (please complete Sections 1 and 2)
        Bank or Driver’s License Change Information
        for Tom Thumb SMARTCHECK Account
        (please tape a new voided check, and complete Sections 1 and 2)                      Other

        Link cards, members of your
        household or a new card to an                                       Existing Reward Card Number (required)
        existing Reward Card number
        (used to maintain participation in promotions
        and other programs)                                                 New Reward Card Number to Link (required)


                                                                                                              Must be at least 18 years of age
                               TOM THUMB REWARD CARD                                                          Incomplete information may result in loss of sweepstakes prize or other offers
                                                                                                                                                                                                                TOM THUMB REWARD CARD CUSTOMER
                                                                                                              *Required Information




     1
                                                                                                                                                                                                                AGREEMENT STATEMENT
                               Last Name*                                                                                         First Name*                                               M.I.                       We respect your privacy. Tom Thumb does not sell, lease or provide
                                                                                                                                                                                                                personal information (i.e., your name, address, telephone number, and bank
                                                                                                                                                                                                                and credit card account numbers) to non-related companies or entities. We
                                                                                                                                                                                                                do record information regarding the purchases made with your Tom Thumb
                               Street Address*                                                                                                                           Apt#                                   Reward Card to send you special offers, personally tailored coupons, and other
                                                                                                                                                                                                                information, provided that you give us complete and accurate information on
                                                                                                                                                                                                                this application. If you DO NOT wish to receive special offers, coupons, or other
                               City                                                                                                         State       Zip Code*                                               information, please check the box below. However, if you check this box, you
                                                                                                                                                                                                                will not be eligible to receive any special programs or offers for which you
                                                                                                                                                                                                                might otherwise qualify through your use of your Tom Thumb Reward Card.
                               Birthdate (month/day/year)                           E-Mail Address                                                                                                                      Check this box only if you DO NOT wish to receive personally tailored
                                                                                                                                                                                                                        coupons or offers from Tom Thumb. By checking this box, you will not be
                                                                                               If you forget to bring your Tom Thumb Reward Card with you,
                                                                                               we can link your card to your phone number.                                                                              eligible to receive any special offers for which you might otherwise
                               Home Phone                                                                                                                                                                               qualify for through your use of your Tom Thumb Reward Card.


                                                                                                                                                                                                                Applicant’s Signature (must be signed to be valid)                               Date




                               SMARTCHECK™ INSTRUCTIONS                                                                                                                   Must be at least 18 years of age      SMARTCHECK™




     2
                               To obtain Tom Thumb SMARTCHECK, you must tape your current pre-printed, VOIDED check to this application. This check will identify the check-
                               ing account from and to which electronic payments and/or refunds will be made. Upon approval, you will receive a letter in the mail notifying you
                                                                                                                                                                                                                CUSTOMER AGREEMENT STATEMENT
                                                                                                                                                                                                                         By signing this application/agreement and later using (or authorizing another person to
                               when your Card is ready for Tom Thumb SMARTCHECK activation.                                                                                                                     use) my Tom Thumb Reward Card at Tom Thumb retail stores, I agree to be obligated by the terms
                                                                                                                                                                                                                and conditions set forth in the agreement which will be issued upon approval of this application.
                                                                                                                                                                                                                I authorize Tom Thumb, its affiliates and subsidiaries to electronically debit the checking account
                              • To pay for groceries using Tom Thumb SMARTCHECK, you MUST use your Reward Card at checkout.                                               IMPORTANT NOTE:                       identified here or, if appropriate, to credit that account to pay for all purchases made and all cash
                                                                                                                                                                                                                received using Tom Thumb SMARTCHECK and my Tom Thumb Reward Card. I understand that
                              • Phone number will not activate Tom Thumb SMARTCHECK.                                                                                      Please Tape VOIDED                    the origination of such transactions from my account must comply with the provisions of U.S. law.
                              • Allow four to six weeks for application processing. One Card per customer.                                                               check. DO NOT submit                   The authorization to complete transactions hereunder will remain in full force and effect until Tom
                                                                                                                                                                             a Deposit Slip.                    Thumb receives written notification from me of its termination in such time and manner as to
                                                                                                                                                                                                                afford it and my bank a reasonable opportunity to act on it. I hereby represent and warrant that
                                                                                                                                                                             A complete updated form is         I have authority to make withdrawals from, and to otherwise bind, this checking account. In the
                                                                                                                                                                             required for any future bank       event my bank denies and returns any electronic check to Tom Thumb, I authorize Tom Thumb to
                                                                                                                                                                           account and/or routing changes.
                                                                                                                                                                           Returned checks, along with the
                                                                                                                                                                                                                electronically re-present my check for both the electronic check amount AND any returned check
                                 Driver’s License Number or State I.D. Number                                                            State Issued                                                           fee and electronic fund transfer fee allowed by state law.
    Now, link your                                                                                                                                                        returned check or electronic fund
Tom Thumb Reward Card                                                                                                                                                    transfer fees, may be electronically
   and your personal                                                                                                                                                           presented to your bank.
checking account in one          Home Phone                                                  Social Security Number
   convenient Card!
                                                                                                                                                                                                                Applicant’s Signature (must be signed to be valid)                               Date

				
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posted:9/8/2011
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