Photo Contest Entry Form - 2005

Name : ___________________________________________

Address : _________________________________________

              _________________________________________

City : _____________________ State : ____ ZIP : _______

Telephone : ______________________________ (Daytime)

                 ______________________________ (Evening)

Years of Age : _________

Number of Entries : __________ 

(Please indicate Image Types & Quantities below.)

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 : _______________________________ 

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