CONGRATULATIONS ON WINNING A PRIZE

FROM 98 KCQ, 97-3 Joe FM and 104 & 92-3 The Bay!

Please fill out the form below to receive your prize!

PRIZE DISCLOSURE

From WKCQ, WMJO, WAM/WSAG (station). Value: TBD

I agree to indemnify and hold MacDonald Broadcasting, WKCQ, WMJO, WAM, and WAG harmless from any and all claims, suits, and actions which may arise out of, or any harms, liabilities or damages I may occur, as a result of my having won the aforementioned prize.

I understand that if I win cash and/or prizes valued at $600.00 or more from MacDonald
Broadcasting Company I will be issued an Internal revenue Form #1099 to report the aforementioned prize(s) as earned income.

In conjunction with the receipt of this prize, I hereby grant MacDonald Broadcasting, WKCQ, WMJO, WSAM, and WSAG permission to use my name and likeness in conjunction with reasonable promotion by the station of my participation in its promotion.

I hereby attest that I am not an employee of MacDonald Broadcasting, WKCQ, WMJO, WSAM and WSAG or it's agencies, nor any member of my immediate family.

Type your name in the box below as a digital signature for this prize!