PA Submission Form – The Smart Cart™

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Financial Institution(Required)

Retail Store Name(Required)

Address(Required)

City State / Province / Region

Product/Service Promoting(Required)

PA Title(Required)

PA Description(Required)

Goals(Required)

Results(Required)

Disclaimer(Required)

I Accept

By submitting this information you are granting FSI permission to post all content from your form to The Smart Cart. Submissions are reviewed quarterly and added to The Smart Cart at FSI’s discretion. FSI reserves the right to withhold any content deemed inappropriate, repetitive, or unfit for the site. You may request removal at any time by emailing Tina Coleman at tcoleman@supermarketbank.com.