These are from SS-10-01-06, same page:

Mfr Cpn Save $1.00 off your next purchase of any Orajel Advanced Tooth Desensitizer Treatment or Orajel Sore Throat Relief Strips
New Orajel Desensitizer can be found in the toothpaste section
5-10310-31076-3-(8100)3-10726 exp.01/31/07

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Mfr Offer:

TRY US FREE!* NEW
*Free offer for Orajel Advanced Tooth Desensitizer 1-count size or Orajel Kids Sore Throat Relief Strips,
based on $1 instant coupon, rebate up to $4.00,
and purchase price of $5.00 or less.
Total $5.00 savings can be applied to purchase of 3- or 6-count sizes of Orajel Tooth Desensitizer.

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Mfr Rebate Details :

Save up to $4.00 by mail
To receive up to $4.00 cash refund, send:
1. Your name, address, city, state, and zip code.
2. The UPC code proof of purchase from the Orajel Advanced Tooth Desensitizer or Orajel Kids Sore Throat Relief Strips box.
3. Dated cash register receipt with the Orajel Advanced Tooth Desensitizer or Orajel Kids Sore Throat Relief Stripsitem price circled.

Mail to :
Orajel® October 2006 $4.00 Rebate Offer, c/o Best Marketing Inc.
P.O. Box 180779
Casselberry FL 32718

Limit one refund per name, family, address, group, or organization.
Offer void where taxed, restricted, or prohibited by law.
Offer good only in the U.S.A., Puerto Rico, or the Virgin Islands.
Allow 6-8 weeks for delivery.
No facsimiles accepted.
EXPIRES 1/31/07


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Notes:
the mfr $4 rebate is NOT a form,
it appears that none is required? (the text is complete as typed above)

did you notice that line "No facsimiles accepted" ?
there is no explanation as to what they are referring to: info slip, or faxes of UPCs and CRT, or....
oh well, probably not important

This is FAR at Rite-Aid this week.