Declaration and Release Form

Axe Adrenaline Men Contest

IN THE MATTER OF the Axe Adrenaline Men Contest hereinafter referred to as THE
SPONSOR, I do hereby state and declare that I,

Name ___________________________________________________________________

Address __________________________________________________________________

City & Province ____________________________________________________________

Postal Code _______________________________________________________________

understand that I will be awarded a $100.00 Gift Card if I correctly answer the skill testing
question printed below within one ten minute period and without any mechanical or other
assistance, and if I otherwise comply with the contest rules, and then return this declaration to
the following address no later than the date stated in the notification:

Axe Adrenaline Men Contest Winner Confirmation

PO Box 25497
Rochester, NY 14625 USA
Email: Print, complete, scan and email to Charlene@ussweeps.com
Fax: Fax, attention Charlene, to (585) 248-1584

Skill testing question: Add 57 + 31

Subtract 52
Multiply by 10
Divide by 36

Answer: _________

I hereby consent to the use of my name and city of residence in a winners list.

By accepting a prize, winner agrees to hold Sponsor its respective directors, officers, employees
and assigns, harmless against any and all claims and liability arising out of use/misuse of prize.
Winners assume all liability for any injury or damage caused, or claimed to be caused, by
participation in this Contest or use or redemption of any prize. Sponsor not responsible for any
typographical or other error in the printing of the offer, administration of the Contest or in the
announcement of the prize. IN NO EVENT WILL SPONSOR BE RESPONSIBLE OR LIABLE FOR ANY
DAMAGES OR LOSSES OF ANY KIND, INCLUDING DIRECT, INDIRECT, INCIDENTAL,
CONSEQUENTIAL OR PUNITIVE DAMAGES ARISING OUT OF ANY PARTICIPANTS PARTICIPATION IN
THIS CONTEST. All participants, as a condition of entry, agree to be bound by these Office Rules
and the decisions of Sponsor.

I HEREBY DECLARE THAT:

1. I am a resident of Canada, and am above the age of majority in the province or territory in
which I reside at the time of entry, and neither I, nor any person with whom I am domiciled, is
employed by THE SPONSOR, their advertising and promotional agencies, prize suppliers, or
parties engaged in the development, production and distribution of materials relating to this
contest.

2. This declaration is, to the best of my knowledge and belief, a true and accurate statement of
the facts contained herein.

3. By signing this declaration, I acknowledge having read, understood and agreed to the above
Release.

Dated at ____________________________________________ this ____________________ day

of _______________________________, 2017.

__________________________________ __________________________________
Signature of Winner Signature of Witness

__________________________________ ___________________________________
Name of Winner Name of Witness

__________________________________ ___________________________________
Address Address

__________________________________ ___________________________________
Telephone Number Telephone Number

Please complete and sign this document.

Return all required documentation per the instructions as outlined in the
original notification you received.
All required documentation are due in our office by the due date stated in the
notification.
Prize will be forfeited if required documentation is not received by the due date.

Should you have questions, call (585) 248-1575 and press 3 or reply to the notification
email you received.