Prize Release Form

Legal Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Bank Account Country *

Currency of Payment (3 letters) *

ex. USD, CAD, EUR

Account Holder Full Name *

PayPal Email *

Confirm PayPal Email *

I confirm the information above is accurate. *

I agree

I grant to Elegant Literature the right to capture or document any statements made by me regarding the Magazine and Contest. I agree that any such captured material may be used by the Publisher for advertising or promotional purposes related to the Magazine, Contest or any similar Contest. In other words: if you tweet about how fun the contest was we can take a screenshot and display it on our website and advertisements. *

I agree

I confirm that I have read, understand, have agreed to, and have complied with the Official Rules governing the Magazine, and the Contest, which was administered by Elegant Media Publishing Corporation. *

I agree