Salute to Everyday Champions!

First Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Phone*

Birth Date (mm/dd/yyyy)

Candidate Email Address*

Your Email Address (if different from Candidate's)

Gender:

Male

Female

Candidate:

Self

Other

Candidate active lifestyle story:

Upload Candidate Photo: (jpg, gif or png):

Disclaimer/Waiver:
By submitting my candidate entry information I agree to give full permission for the use of the candidate photo and story on www.revupenergyboostcapsules website as well as on other printed promotional materials. This event is being sponsored and promoted by Upfront Marketing, Inc. and neither Upfront Marketing, Inc., or any of it's employees, staff or others affiliated with Upfront Marketing, Inc., or the Everyday Champions promotion will be held responsible for any misuse or infringement of the candidate's photo or story. All other information entered on this form will be kept private and confidential and will not be shared with any entity outside of Upfront Marketing, Inc. and contact information will be used only in conjunction with the candidate entry for purposes of awarding recognition or keeping candidate informed of progress of the promotion.
I Accept the terms of the waiver


	WHY PAY MORE? RevUp Costs HALF what the leading Energy Shot Costs - for the same benefits!