“SHOP, PLAY, WIN!

® MATCH 3 DIGITAL GAME”

CUSTOMER HIGH-LEVEL PRIZE FORM
(Prize Submission Agreement)
MON-14

NOTE: IF VERIFIED A WINNER, YOU WILL BE CONTACTED BY

EMAIL & THIS PRIZE WILL BE SENT TO YOUR HOME GROCERIES
Attached is a Customer Digital Coupon that I wish to submit for checking
and verification to determine whether or not it is a winner. I understand FOR A WEEK
that I will not be a winner unless and until this Customer Digital Code has
been verified. ($100 Grocery Gift Card)
I hereby represent that I am not an Employee or Employee’s family Write in your Digital coupon code for this prize submission:
member (wife, husband, or family member living at same address) of
Albertsons, ACME Markets, Jewel-Osco, Shaw’s/Star Market, Lucky,
Safeway, Pavilions, Carrs, Vons, Randalls, Eagle, Pak ‘n Save, Tom Thumb,
Market Street, Amigos, United Express, United Supermarkets, Super Saver,
_M _X M_ M_-_1 _M _V X_-_4 _T _7 5_-_2 _G _V _T
the game supplier, or any other company engaged in the development and Code registered on website
production of the game materials. Upon signing this waiver and release
form, any and all taxes connected to this prize will be my responsibility.
Prize payment may take up to 60 days from the date of verification. Once
verified, I agree to provide a valid copy of my Driver’s License or Passport Affix your
to verify age and identity.
ORIGINAL
I further agree that I have read and agree to be bound by the Official
Rules of this promotion and that the date and time on this Prize
Digital
Submission Agreement are correct. coupon here
In the event that the game materials submitted are verified by authorized
personnel and no material is found to be illegible, altered, mutilated,
defaced, tampered with, forged, contains printing or other errors, or is _______________ ________________
irregular in any way and I am declared a winner, the game sponsor or Date Time of day
its affiliated companies have my permission to publicize this fact and
to use my name, voice, likeness and/or picture in their advertising and _______________________________________
sales promotion materials or in any advertising media without further Print Customer e-mail address
compensation to me.

Make a photocopy for your records _______________________________________

Print Customer Name
Send to:
Creative Promotional Solution, Inc. ________________ _________________
Telephone Number* Date of Birth
975 Cobb Place Blvd.
Suite 213 __ __ __ __ __ __ __ __ __ __ __ __ __ __
Kennesaw, GA 30144
Certified Mail is recommended. You may choose to use UPS
OR FED EX for tracking purposes. Sponsor is not _______________________________________
responsible for late, lost, or misdirected mail. Print Street Address/P.O. Box Number

Distribution: ________________ ______ _______

Original - Creative Promotional Solution, Inc. City State Zip Code
Photo Copy - Participant’s receipt
Submission must be received _______________________________________
by Verification Center: Signature of Customer Submitter

5/27/21 _______________________________________
Name of Store
EEEEEEAuthorized personnel onlyEEEEEEE
Verification by CPS, Inc. __________________________ ______
q This prize submission has been reviewed & verified by: Store Street Address Store #

Initials Date
________________ ______ _______
City State Zip Code
qP qF *Telephone Number will be used for contact, if submission is verified.