AFFIDAVIT OF ELIGIBILITY AND RELEASE
State of )
County of ) I, ___________________________,
being duly sworn, depose and say that:
I am being considered as a prize winner in the Lenox Opal Innocence Metal Unity Candle Holder Giveaway, and to satisfy the eligibility requirements, I hereby certify that I am a legal US resident (void in Puerto Rico and where prohibited by law), that I am age 18 or older or of an age of the majority in my state. I hereby certify to the following data:
HOME ADDRESS (Please Print)
______________________________________________________
City _________________________________
State_______________________ Zip___________________
DAY PHONE (____) ____________________
EVENING PHONE (____) ____________________
AGE __________
I HEREBY AGREE:
That weddingcandledecor, their parent, companies and any of its or their subsidiaries, affiliates, advertising and promotion agencies and all of their respective officers, directors, employees, representatives and agents may use (unless prohibited by law) my name, picture, portrait, likeness, and voice for advertising and promotional purposes without further consideration;
-that my entry may automatically be disqualified if this affidavit is not postmarked by March 31, 2010.
-that all Federal, State and other taxes and charges on the prize I may win will be my sole responsibility, and that I will provide my Social Security number if necessary for a Form 1099;
-that I have read and agree to abide by the Official Rules of the Giveaway;
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-to hold harmless weddingcandledecor, and their parent companies and any of its or their subsidiaries, affiliates, advertising and promotion agencies and all of their respective officers, directors, employees, representatives and agents from any and all liability, claims or action of any kind whatsoever for injuries, damages or losses to persons, including myself, and property which may be sustained, in whole or in part, directly or indirectly in connection with the receipt, acceptance, possession, use or misuse of a prize, while preparing for, participating in and/or traveling to any prize related activity and participation in this promotion; and
-I understand that if I make any false statements herein, I will automatically be disqualified.
_________________________________ Sworn to and subscribed by me this
Your signature
___________________________________
________________________ day of ____________, 2010
____________________________
NOTARY PUBLIC (signature)
Please return this affidavit to:
____________________________
Bey Scent and Candle Company
201 North 3rd St. Apt. 328
Allentown, PA 18102
