After Printing This Form Click Your Back Button To Return To The Contest Pages Contest #________Contest Theme _________________________________ Contest Deadline Date____________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 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________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ENTRANT INFORMATION NAME:_______________________________________ ADDRESS:___________________________________ ____________________________________________ ____________________________________________ CITY__________________________________________ STATE_________________________________________ ZIP CODE______________________________________ ____________________________________________ COUNTRY____________________________________________ TELEPHONE:_(_____)__________________________ AGE:______ I have read and understood the rules and requirements attached to this official entry form and I agree to be bound by these rules and regulations and the decisions of the judges. I hereby assign any/all rights, title and interest, including copyrights, I may have in the enclosed poetry and writing to USANationals.Com and I consent to possible publication of the poems and writing, if selected as a winner, together with my name, age, and address, without additional compensation beyond the cash, prize and award and recognition given to me for winning. Signature of Entrant * ________________________________________________Date_________________ *Entry will be void without signature Signature of Parent or Guardian ** ________________________________________________Date_________________ ** If entrant is under 18 years of age, entry will be void without Parent/Guardian's signature. If paying by credit card you may submit on line or fill in credit card information below. Do Not mail in if you have submitted your entry, poem and fee/donation on line. Type of Card: Visa____ MasterCard____ Discover____ Card Number:__________________________________________ Expiration Date: ______________________ The credit card is in what name?:____________________________________________ Signature: __________________________________________ $1.00 All ages Mini Contest to win cash and prizes up to $5,000.00 Pay donation/fee below to win cash and prizes up to $500,000.00 $10.00 adults (18 years old and older) $8.00 for Teens 11 to 17 years old $5.00 for Youth 7 to 10 years old $3.00 for Kids up to 6 years old If you are sending your entry and fee by mail: Send entries and an entry fee/donation for each entry in a stamped envelope to: Global Media 385 Talbot Street, #7 Pacifica, California 97044 USA Make checks and Money Orders payable to: Global Media & Communications, Inc. For additional information, please call (650) 359-3324