Farm $5 PCMO Cash Back Program

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Your Information

First Name*

Last Name*

Address Line 1*

Address Line 2

City*

State*

Postal Code*

Phone Number

Email Address*

Please select which purchase(s) apply

Conventional Daily Protection (5 Quart Jug)

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Extended Protection Full Synthetic (5 Quart Jug)

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Extended Protection Full Synthetic (Quart)

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Conventional Daily Protection (Quart)

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Extended Protection Full Synthetic High Mileage (5 Quart Jug)

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Full Synthetic Advanced (5 Quart Jug)

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Full Synthetic Advanced (Quart)

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Extended Protection Full Synthetic High Mileage (Quart)

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European Full Synthetic (5 Quart Jug)

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SynPower (5 Quart Jug)

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SynPower (Quart)

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European Full Synthetic (Quart)

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Hybrid Full Synthetic (5 Quart Jug)

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Full Synthetic High Mileage (5 Quart Jug)

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Full Synthetic High Mileage (Quart)

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Hybrid Full Synthetic (Quart)

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MaxLife High Mileage (5 Quart Jug)

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Racing Conventional (Quart)

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Racing Conventional (5 Quart Jug)

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MaxLife High Mileage (Quart)

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VR1 Racing (5 Quart Jug)

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DuraBlend (5 Quart Jug)

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DuraBlend (Quart)

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VR1 Racing (Quart)

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Modern Engine (5 Quart Jug)

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Modern Engine (Quart)

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Retailer Information

Retailer Name

Please select how you want to be paid: For Venmo and Paypal, you will receive an email from Hyperwallet to complete transaction.

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Digital Payment (Paypal/Venmo)

Proof of Purchase

Please upload all applicable receipts/invoices. Acceptable file formats are JPG, JPEG, PNG and PDF with a maximum file size of 5MB.

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