A2 Fiber Contest Entry Form

Fill out this form to enter the LA2M A2 Fiber You Tube Video Contest. You must fill out this form completely and confirm that you have read the complete contest Rules and Regulations here: http://la2m.org/a2-fiber-you-tube-contest-rules. All entries must be received by Friday, April 2 at 12:59 PM.

Full Name: *

Age: *

Email Address: *

Phone Number: *

Address: *

City: *

State: * select...AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

YouTube Entry URL: *

Please enter the full web address (URL), including the http:// prefix, of the YouTube video you want to submit.

I have added my video to the A2 Fiber YouTube Contest Group on YouTube.: *

YES

How did you hear about the contest (Max 500 characters):

I have read and agree with the contest rules.: *

Yes

No

Read Contest Rules Here: http://la2m.org/a2-fiber-you-tube-contest-rules

Electronic Signature: *

By typing my name here I am affixing my electronic signature and certifying that all of the above information is correct; the submitted video is an original work created for this contest; and I accept the terms of the contest as stated on this web site.

Parent/Guardian Full Name:

If under age 17, please provide your parent or guardian's contact information.

Parent/Guardian Email:

Parent/Guardian Phone Number:

Attachment	Size
a2fiberyoutubereleaseform.pdf	110.33 KB