Asked for a rebate for a new referral but forms are not understandable

This info was not confusing it was trying to find the right info to register the customer I was talking with the representative and info was not entering into the system-do not know if you have the info on the customer or not but it is [removed email, never post personal info] Act #34064311 Service date 7/2/2016 please confirm that you have received this info Thank you in advance