Kick Back Rewards Sign Up

Do you have a new points card you need to register?
Please fill out the form below to complete your registration.
If you don’t have a card yet, stop by any of our locations to pick one up!

Card Registration

Card Number*

Activation Code*

6 digit code on the back of your loyalty card

Name

First Name*

Last Name*

Address

Street Address*

Apt, Suite, etc.

City*

State*

Zip*

Mobile Phone & Email

Mobile Phone

Please do not include dashes, spaces, or parentheses.

I want receive messages and offers.

I agree

Card Pin

Please choose your 4-digit PIN *

By submitting this form you agree to the term and conditions at Kickback Systems