Name (first & last):

License #: License Type: State of Issue:

Salon Name:

Home Address:
(Street address ONLY - no PO Boxes)

City: State: ZIP: Country:  

Daytime Phone Evening Phone

Email Address: FAX:

Category (check one box Only)

Enhancement Sr.
Enhancement Jr.
Mixed Media Sr.
Mixed Media Jr.

I verify that:
All material is original, has not been used in any competition online or offline.
I am qualified to enter the chosen category.

PLEASE CHECK ONE BOX BELOW -- REQUIRED:

I am a US resident, the above information is a US street address where I receive my mail.

I am not a US resident, I can provide a US street address for my prizes
Ship my prizes to (care of Name):
Street Address:
(Street address ONLY - no PO Boxes)
City: State: ZIP: Country:  
Daytime Phone

I am not a US resident, I can not provide a US street address for my prizes. I understand I may be asked to pay postage/freight for some of my prizes, and I understand I may not receive all of my prizes due to high shipping costs/restrictions.

REQUIRED:
I understand my Name, address, phone number and email address will be shared with all participating companies.