Uniprix Beauty Card Registration Form

• First name*:
• Last name*:
• Language*: Français Anglais
• Gender*: Male Female
• Date of birth: ex : yyyy-mm-dd
• Address*:
• City*:
• Postal code*: ie: h1h 1h1
• Telephone*: ie: (514) 555-5555
• Email*:
• Are you an Aeroplan member*: Yes No
• Aeroplan number:
• I would like to receive the Uniprix newsletter and occasional information on products, services and promotions from Uniprix and its partners.
• I would like to receive an email alert for the online Uniprix flyer.

Print this coupon and present it at your local Uniprix.