WIN! CLAIMS FORM | When Words Count Retreat

If you are human, leave this field blank.

#1. Complete and submit this form before the prize-claim deadline.

#2 Include your certificate discount code in the space provided (Late submissions will be disqualified.)

First Name*

Last Name*

Your Certificate Discount Code*

Primary Email*

Home/Cell Phone*

I am a published author currently writing on a new book.*
I am a citizen of the United States or Canada, who is at least 18 years of age and am currently writing a new book.

I attest to the truthfulness and accuracy of the personal information provided above and hereby incorporate it into the Affidavit of Eligibility and Standard Release forms below.*
I attest to the truthfulness and accuracy of the personal information provided above and hereby incorporate it into the Affidavit of Eligibility and Standard Release forms below.

Choose your Alternate May Prize Date(s) below, entitling you to a FREE Room for a 3-Day/Two-Night Stay in May, should you later qualify for a 3rd-Place prize.)

First Choice

Month*

Days *

Second Choice:

Month*

Days *

Please read carefully and then approve each of the following documents:

I agree to terms and conditions of Affidavit of Eligibility (read)*
I agree to terms and conditions of Affidavit of Eligibility (read)

I agree to terms and conditions of Standard Release Form (read) Affidavit of Eligibility (read)*
I agree to terms and conditions of Standard Release Form (read)

Also, for your convenience, you may download the forms, print, complete,
sign and return them by mail (hard copy) or email (scan).

Email: sales@whenwordscountretreat.com

Mail: Sales c/o When Words Count Retreat

1764 Marsh Brook Road

Rochester, VT 05767

¹Limit: one certificate per customer, per room. Non-transferrable. May not be combined with any other offer. Cash surrender value: 1/10,000 of a cent. Good only for WWC Retreat Stays in June, 2013. Valid through 11:59 p.m. EST Monday, March 18, 2013 and only if activated by completing prize-claim process.