Please complete this form and click the submit button at the bottom. * Required fields
*Request Date (MM/DD/YYYY):
*Select Request Type (Check one):

New Enrollment
(If AAA Repair/Service Provider has a NAPA account – Please complete Sections 1, 2 & 3)
New Prospect NAPA Lead
(If AAA Repair/Service Provider does not have a NAPA account - Please complete sections 1&3)
1. AAA Repair/Service Provider Information
*Company Name:
*City: *State:  *Zip: 
*Owner Name:
*Email Address:
*Current NAPA AutoCare Member?:
If yes, enter your AutoCare Member #:
2.  NAPA Store Account Information (Required for NAPA-AAA program enrollment)
      This information can be found on the providers NAPA store invoice
NAPA Store #:
NAPA Account #:
NAPA Store Phone #:
3. AAA Club Information
*AAA Program Type: (Check all that apply)
*# of Trucks: # of Service Bays:  
*AAA Provider Location #:    
*AAA Club Name: Club #:  
*AAA Representative Name:
*AAA Representative Email:
*AAA Representative Phone:

Disclaimer: Please allow up to 6 weeks to process request. Service providers may only participate in one NAPA rebate program of their choosing (in addition to NAPA AutoCare). AAA enrollment must be completed before purchases count towards the minimum quarterly purchase requirement or earn rebates. Quarterly rebates only applicable to providers who are a) enrolled into the AAA / NAPA program with NAPA; b) have an active account with their local NAPA AUTO PARTS Store; and c) contracted with AAA club at end of the calendar quarter.

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