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Text File  |  1993-08-01  |  866b  |  34 lines
  1.  
  2. AFFIDAVIT OF ELEGIBILITY AND RELEASE 
  3.  
  4. STATE OF ______________________ 
  5.  
  6. COUNTY OF ______________________ 
  7.  
  8. Name of winner: ________________________________________ 
  9.  
  10. Name of contest: ______________________________________ 
  11.  
  12. Date of winning: ________________________ 
  13.  
  14. Date of receipt of prize: ________________________ 
  15.  
  16. Enter description of prize: ______________________________________
  17.  
  18. The undersigned, ________________________________________, hereby
  19. being sworn to tell the truth states: 
  20.  
  21. That they are the winner of the prize described above. 
  22.  
  23. That they were eligible under the rules and regulations of
  24. ____________. That they consent to use of their name, image and
  25. likeness by STATION. 
  26.  
  27. That their taxpayer identification number is:
  28. ________________________________________
  29.  
  30.  
  31. ________________________________________
  32.  
  33.  
  34.