| Are you submitting a Birthday or Anniversary: |
|
|---|---|
| Who is having the Birthday/Anniversary: | |
| Where Are they From: | |
| How old are they/How many years have they been married (optional): | |
| What is their Birth Date or Anniversary Date: | |
| What Phone Number can we call if they win a birthday prize: | |
| What is your Email Address: | |
| Additional Information (optional): | |
| Comments: | |