Contest application



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Date06.02.2017
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SMILE MAKEOVER CONTEST

Presented by: Dr. Kimberly Neiman, DDS

Awarding Dental Care and a Personal Makeover to one Lucky Resident
CONTEST APPLICATION
DATE: ____________________

NAME: _______________________________________________________________

ADDRESS: ___________________________________________________________

CITY: __________________________ STATE: ______ ZIP: ____­____________

HOME PHONE: ___________________ MOBILE PHONE: _________________

DATE OF BIRTH: _________________

EMAIL ADDRESS: ___________________________________________

Thank you for your interest in our Smile Makeover Contest! The following items must be received no later than June 27, 2013 in order to be considered for the contest.*


_____ Completed Contest Application Form

_____ Brief description of your dental care needs

_____ 300-500 word essay telling us how you bring a smile to others and why we should makeover your smile

_____ Current photograph of your face and also a close up of your smile


Please submit all required items by bringing or mailing your entry package to:
Dr. Kimberly Neiman, DDS

217 N. 4th Street

Wills Point, Texas 75169
*Any entries that do not include all required items will be void. Any entries received after June 27, 2013 cannot be considered for a prize. Any entrants that do not meet all Eligibility Requirements as stated in Contest Rules will not be eligible to participate.
Dr. Kimberly Neiman will be awarding one lucky winner the chance to receive a Smile Makeover (to be performed between July and December 2013). The selected winner will receive up to $10,000 of dental services, as well as select personal makeover services offered by our Smile Makeover Team. After the winner has completed their makeover, they will have the chance to report on their experiences and step into the limelight to have photographs taken and share their “smile story” through our media partners. Best of all, the entire Smile Makeover experience will be free of charge! ^
Don’t delay! Submit your entry package today and take the time to put a smile on your own face for a change!

ESSAY RESPONSE
Please answer all questions on a separate piece of paper.


  1. How do you share a smile with the community?

  2. Why do you deserve to win our Smile Makeover Contest?

  3. Please tell us briefly about your dental care needs. Please indicate any information that you would not like to be publicized and it will remain confidential.

By submitting this Application and Essay and signing below I verify that (please initial by each entry):



_______


I am 21 years of age or older and currently reside within a 30 mile radius of Wills Point, Texas;

_______


I am willing and able to participate fully in the Smile Makeover process and I am committed to completing my Makeover;

_______


I authorize Dr. Kimberly Neiman DDS and the Contest Organizers to use my name, photo, image, essay contest statements and voice for publicity purposes, without any form of monetary consideration;


_______


If I have any significant health issues I agree to sign an authorization form to allow Dr. Neiman to discuss said issues with my physicians;


_______


I release and discharge Dr. Kimberly Neiman DDS and the Contest Organizers from any and all liability with respect to any damages I may incur as a result of participating in the Contest;

_______


I agree to read and sign the Official Contest Rules for the Smile Makeover Contest before starting the makeover process; and


_______


All information and statements included in my Contest Application and Essay are true and correct to the best of my knowledge.


____________________________________ ______________________________

SIGNATURE PRINTED NAME
____________________________________

DATE


 We are not responsible for mailed packages not received

^ Winners are solely responsible for reporting and payment of taxes on any and all prizes received



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