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Please enter the following pieces of information from your receipt.
Store Number: Input Store Number.
Receipt Number: Input Receipt Number.
Date: VisitDateMonth -- 010203040506070809101112 / Day -- 01020304050607080910111213141516171819202122232425262728293031 / Year -- 2425
Time: Hour -- 010203040506070809101112 : Minute -- 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AM or PM -- AMPM
Upon completion of this survey, you will be given a validation code that can be used to redeem the offer printed on your receipt.