2016-17 CONTEST BALLOTS CURLING CLUB NAME: _________________________________________________ DATE: _________________________________________________________________ WFG AGENT: __________________________________________________________

First and Last Name Contact Information (Winners will be contacted through this information)

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#2 Phone:

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#3 Phone:

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#4 Phone:

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#5 Phone:

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#6 Phone:

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#10 Phone:

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I agree to be contacted directly by the Contest Administrator, The Republic Agency Corp, should my ballot be selected as the winner

I consent to the Contest Administrator, The Republic Agency Corp., notifying my Curling Club that I am a winner and providing

my contact information to my Curling Club

By submitting the above information, you agree to participate in the Everest-Ferbey National Pro Am contest and confirm that you are in compliance with all applicable rules and regulations found at www.everestfuneral.ca/curling. The information provided above is used for the purpose of this contest only.

Please use ONE of the following methods to submit your club’s ballot sheets each month:

• Scan and email to everestferbey@gmail.com • Fax to 416-537-7044 • Mail to: The Republic Agency Corp. Attention: Alycia Walker, 219 Dufferin Street, 10A, Toronto, Ontario. M6K 1J3