Mountain State $100k Prediction Form

Printable Submission Form

Mountain State $100k Prediction Form

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OFFICIAL ENTRY DOCUMENT

Mountain State $100k Score Prediction Form

PROVENIQ Foundation • Mail-In Fallback Entry

Entry Date

1) Participant Information

Full Legal Name Phone Household Street Address City / State / ZIP Email Mayday or LifeLog Account Email (if applicable) Registered Pet Name Microchip ID (if known)

2) Prediction Entry

Prediction Value / Guess Tie-Breaker Timestamp (optional) Reasoning (optional)

3) Charitable Award Direction

Preferred WV 501(c)(3) Shelter / Rescue Name County Charity Contact (optional)

4) Certification

I certify that I am a West Virginia resident and this is the only entry from my household. I agree to the official rules published by the PROVENIQ Foundation.

I affirm the certification statement above.

Signature Date