Contest Entry Form

Name : ___________________________________________

Address : _________________________________________

_________________________________________

City : _____________________ State : ____ ZIP : _______

Telephone : ______________________________ (Daytime)

______________________________ (Evening)

Years of Age : _________

(Please indicate Image Types & Quantities below.)

	Originals	Duplicates
Prints	______
Digital Images	______
35mm Slides	______	______
Other Transparencies	______	______
Total number of images submitted : __________

Do you belong to a Photography Club? Yes or No

If so, what is the Club's Name: ___________________________

If one or more of my entries is selected, I agree to Black River Publishing's use of the selected entries for publication & promotion. I have read the contest rules and affirm that this entry is in compliance with them. I understand that Black River Publishing assumes no responsibility for the slides submitted.

Signature of Contestant : _______________________________

Date: ___________

If under the age of 18,
Parent's or Guardian's Signature : _________________________

Form : Y04HMTL v6

(Photocopies and facsimiles of this form are acceptable for submission)

Photo Contest Entry Form - 2004

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