Jackson Chance · NICU Baby of the Year Partner

Name

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First Name

Last Name

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

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Email

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Verify Email

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Company/ Brand

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Company/ Brand Logo

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PNG or EPS files only

Instagram Handle

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Facebook Link

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What level partner would you like to be?

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Credit Card Type

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Credit Card Type

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Credit Card Type

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Credit Card Type

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Credit Card Number

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Credit Card Number

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Credit Card Number

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Credit Card Number

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Expiration Date

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(mm/dd/yyyy)

Expiration Date

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(mm/dd/yyyy)

Expiration Date

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(mm/dd/yyyy)

Expiration Date

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(mm/dd/yyyy)

Security Code

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Security Code

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Security Code

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Security Code

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Is the address above the same as the billing address?

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Yes

No

Is the address above the same as the billing address?

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Yes

No

Is the address above the same as the billing address?

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Yes

No

Is the address above the same as the billing address?

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Yes

No

Billing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Billing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Billing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Billing Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Item Description

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Are there any restrictions and/or an expiration date?

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Item Value

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Do you have an optional 2nd prize?

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Yes

No

Item Description (2nd)

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Are there any restrictions and/or an expiration date? (2nd)

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Item Value (2nd)

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How will your item be delivered?

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Please mail your prize to: Jackson Chance Foundation | 1953 N Clybourn Avenue | Suite R #311 | Chicago, IL 60614

Please email the tracking number to mary@jacksonchance.org.

Please enter the Winner's code to redeem their prize.

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If the code will be sent at a later date, please enter N/A.

Please email certificate to mary@jacksonchance.org.

Please contact Mary Sullivan at mary@jacksonchance.org to schedule your pick up or drop-off.

I confirm that during the campaign the brand will share about the JCF Baby of the Year Campaign through social media and email in an effort to draw more awareness to this cause.

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JCF will provide assets and copy for usage.

Yes

No