COUPLES4LIFE MONTHLY DRAWING
ENTRY FORM

--- Your PRIVACY is assured! ---
All data you provide to us is held in the strictest of confidence
and your personal information is never sold, rented, leased, or otherwise disclosed to third parties or any outside sources.

One winner per drawing. Winner will be notified via email.

No Purchase Necessary. Product & Shipping is completely free to the winner.


First Name:

Last Name:

E-mail Address:
Important: your EXACT return E-mail Address is REQUIRED
(it will be used to notify you if you won this month's drawing)

Shipping Address:

City:

State/Province:
(contest is available only to U.S. & Canadian residents at this time.)

Zip/Postal Code:

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Thank you for entering our monthly drawing!