HomeWinner AcknowledgmentWinner Acknowledgment SHARE NOW Prize Collection Authorization Winner’s Full Name(Required) First Last Email(Required) Phone Number(Required)Winner’s Full Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Station(s) and/or Website(s)(Required)Please add the Regional Media Station and/or Website you used.Date Picked up(Required)Enter Today’s Date MM slash DD slash YYYY Item(s) Won(Required)Please let us know what's on your mind. Have a question for us? Ask away.Agreement(Required)Heartfelt congratulations on your recent win, presented in association with Regional Media - Virden Broadcasting and its partners. By signing this document, you acknowledge and consent to take full responsibility for any potential incidents or damages that might occur once the prize is in your possession. This signature is a binding agreement that you fully absolve and release Regional Media - Virden Broadcasting and all associated sponsors, including their owners, staff, agents, officers, legal successors, and assigns, from any claims, losses, damages, or expenses that may arise post-receipt of the prize. You agree to be solely responsible for all applicable income, state, federal, and local taxes, as well as documentary fees and temporary tag fees associated with the prize. Prize collection is to be done in person at Regional Media - Virden Broadcasting office during standard business hours where ownership of the prize will be officially transferred upon your collection. Your signature below also acknowledges your responsibility for all related expenses. You agree to cover these costs and indemnify and hold Regional Media - Virden Broadcasting and all sponsors harmless for any such expenses. I Accept.Signature(Required)CAPTCHA
