[NOTE: This form is now 100% VOID!]

Sweepstakes

Form A

First Name: ______________________________
Last Name:  ______________________________

The following information is optional.   I
would recommend that you include it, as it
will allow me more than one way to contact
you should you win.   It will be kept 100%
confidential.

Address: _________________________________
City:    _________________________________
State or Province: _______________________
Zip:     _________________________________
Country: _________________________________
Phone:   (___) ___-____
Secondary email address: _________________


On what day will the child be born?

Month            ________________
Day of the month ________________
Year             ________________


Email this form to bekinder@ucollege.edu