Claimformsss

CLAIM FORM FOR GIFT
CONFIRMED GIFT DELIVERY ADDRESS
Name:

_______________________________________________________

Address:

_______________________________________________________

Email Address:

_______________________________________________________

Phone Number:

_______________________________________________________

ACKNOWLEDGEMENT OF TERMS
I, ______________________________________ (Print Full Name), certify that I am over eighteen (18) years of age. My date of birth is _________________________.
I am submitting this Claim Form with the understanding that it will be relied upon to verify and confirm my entitlement to receive the sponsored Gift by Surveys Samples &
Savings.

(______)
Print
Initials

In consideration of the receipt of the Gift, I hereby release and forever discharge the
Sponsor and its officers, directors, employees, subsidiaries, affiliates, agents, assigns, etc. or any entity or person connected with the Gift from and against any and all claims, demands, losses entitled to assert, including but not limited to any death, injury, loss of enjoyment or other harm or loss of any nature whatsoever caused by, contributed to, or arising out of any gift awarded to me in this promotion.

(______)
Print
Initials

As stated, I understand that the Gift I qualified for consists of a general gift valued at up to $25. Surveys Samples & Savings reserves the right to substitute my gift with a gift of equal or greater value depending on the availability of the original gift.

(______)
Print
Initials

I understand that I will be disqualified from receiving any gift which may be awarded to me if any statement made by me on this Claim Form is false and/or incorrect.

(______)
Print
Initia

_______________________________________
Sign Name (Required)

_______________________________________
Print Full Name (Required)

_______________________________________
Date (Required)

_______________________________________
Claim Number (Required)

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