Better Your Smile 2012

First Name:

Last Name: 

Address:  

City, State, ZIP:

E-mail Address:

Home Phone:

Work Phone:

Cell Phone:

Age:

Sex: Male  Female
Profession/Employer:

Help us understand how your smile may influence your career:

If you are selected as a finalist, we would need to contact your dentist to obtain copies of your dental records.
Who is your dentist?
When was your last appointment?
What was done?

Have you been advised to have your teeth pulled?
Yes  No

Are you missing any teeth other than your wisdom teeth?

Explain how your smile has negatively impacted you socially or in your occupation:

What are you most interested in accomplishing?

What has prevented you from receiving treatment in the past?

Please list any medical condition you have been treated for in the past, or are currently being treated for:

417 Magazine Rules and Regs 1) You do not need to provide consideration to anyone to enter. 2) No purchase necessary. 3) Prize includes those stated on contest entry page. 4) To enter, complete and submit the form on the contest entry page. 5) Entrants agree to be bound by these Rules & Regulations. 6) The contest is run by 417 Magazine, who is solely responsible for conducting the contest and for awarding the prize. 7) 417 Magazine shares the information collected from Sweepstakes entries with our Sweepstakes partner(s). By entering your email address on the sweepstakes entry form, you consent to receive promotional email from 417 Magazine and our advertisers. 8) Entries must be received before contest closing date. 417 Magazine and our Sweepstakes partner(s)(which means any business, individual, or organization mentioned or otherwise referenced on the contest entry page, other than in banner advertisements presented through the DoubleClick ad management system), are not responsible for late, lost, damaged, or misdirected entries, or any technical malfunctions of the telephone network and/or transmission line, computer on-line system, computer equipment, hardware, software, or any combination thereof, or any entries that are late (including delayed data transmissions), tampered with, garbled, incomplete, misdirected, lost, mutilated, delayed, corrupted, mechanically duplicated, illegible or otherwise not in compliance with these Rules & Regulations. Entrants also agree that 417 Magazine and our Sweepstakes partner(s) are not responsible or liable for any injury or damage to an entrant's or third person's computer related to or resulting from Sweepstakes and its prizes. 417 Magazine and our Sweepstakes partner(s) are not liable for damage to a user's computer system in any way due to an entrant's participation in the Sweepstakes or downloading any information in connection with the Sweepstakes, including without limitation any server failure, lost, delayed or corrupted data or other malfunction. 417 Magazine and our Sweepstakes partner(s) reserve the right to modify or cancel the Sweepstakes in the event that it becomes technically corrupted. 9) Entrants agree that 417 Magazine and our Sweepstakes partner(s) shall not be liable for losses or injuries of any kind resulting from acceptance/possession and/or use/misuse of prize(s) or participation in Sweepstakes. Winners and travel companions must sign a release form and have the form notarized. The form releases all of the participating companies and sweepstakes partners from liability arising from the prize. 10) Entrants must be US residents at least 21 years of age. 11) Employees of 417 Magazine, our sweepstakes partner(s), participating companies, and their ad agencies, (and members of the immediate families of each) may not enter. 12) LIMIT OF ONE ENTRY PER PERSON AND PER EMAIL ACCOUNT. If there is a dispute about who the email address belongs to, it will be deemed submitted by the email account holder. If multiple entries are received, only the first entry will be considered and subsequent entries will be disqualified. 13) The winner will be selected in a random drawing or selected by 417 Magazine and our Sweepstakes partner to be held after the contest has closed. Winner will be notified by phone call. If the winner does not respond to the phone call within two days, they will forfeit the prize, and a new winner will be selected. Odds of winning depend on the number of entries received. 14) Federal, state and local taxes are the responsibilities of the winner. Prize awarded based on availability. All expenses not specifically part of the prize according to the contest entry page, including transportation, are the responsibility of the winner. Void where restricted by law; federal, state and local laws apply. No substitution for prize. Prize is not transferable, and is not redeemable for cash. Decision of judges is final. 15) Any submitted photos or written material may be used or re-purposed on our website, in print or digitally by Whitaker Publishing currently or in the future 16) For winner's name, send the contest name and a self-addressed stamped envelope to Megan Johnson, 417 Magazine, 2111 S. Eastgate, Springfield, MO 65809.

YES, I agree to the following terms and conditions outlined above

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