Name
Address
City
State
County
Zip
Email
Telephone
Date of Birth
Country of Birth
Country of Citizenship
Number of Dependents
Do you owe any back taxes? YesNo
Social Security Number (SSN)
Are You Currently Employed? YesNo
Have you ever been convicted of a criminal act? YesNo
If yes, please state the nature of the offense
Do you have a valid Government issued ID? YesNo
What is your marital status?
Married
Single
Divorced
Widowed
What was your occupation?
Annual Household Income ?
Are you the owner of your home? YesNo
Are you the one who takes care of your own finances? YesNo
Do you currently have investments (stocks, bonds, annuity, 401(k)s, IRA)? YesNo
*I guarantee that all the above information is true and factual in its entirety. I understand that any false information or failure to comply may result in my prize money being barred from entering the country by the IRS.
Signature of Applicant
Date
