# Register to Win!

First name: |
Last name: |
E-mail address: |
State of residence: |
Zip code: |
Age: | 18-24 25-34 35-49 50-64 65+
Education: | High school BA/BS Masters Ph.D. other
Interests: | Camping Sports Movies Music Books Photography other

Fields highlighted with red labels must be filled in
Underlined fields must be filled in

Mail to:
Make Me A Winner Inc.
4141 West 42nd St.
Old York, OK 00100-1010