Event Prize Claim Form Prize Claim Form Please complete this form to claim your prize. Today's Date(Required) MM slash DD slash YYYY Name(Required) First Last Email(Required) Mobile Phone Number(Required)Mailing Address(Required)Please enter the address to mail your prize below. Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Prize SelectionOnce recieved, prize will be shipped to the mailing address listed above. Prize will be delivered via USPS ground within 30 days of receipt. How many prize(s) are you claiming?(Required) 0ne (1) Prize Two (2) Prizes Three (3) Prizes Prize #1(Required) Optometry Divas Journal Notebook Optometry Divas Beach Bag Optometry Divas Penlight with Pupil Guide Other Prize #2(Required) Optometry Divas Journal Notebook Optometry Divas Beach Bag Optometry Divas Penlight with Pupil Guide Other Prize #3(Required) Optometry Divas Journal Notebook Optometry Divas Beach Bag Optometry Divas Penlight with Pupil Guide Other
