Alternate Winner Acceptance Form

Alternate Winner Acceptance Form
Please confirm your acceptance of the prize or award as an alternate winner. Complete all required fields to proceed.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address (if required for prize delivery)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Prize or Award Name
Prize Notification Date
MonthDayYear
Date
Preferred Delivery Method
Alternate Winner Reference Code (if provided)
Acceptance Confirmation
Signature
Powered by Jotform SignClear
Should be Empty: