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2013 Nomination Application
Today's Date:Family Name:Home Address:City:State:Zip:County:Mailing Address same as Home Address?YesNoMailing Address:City:State:Zip:Phone:Alternate Phone:E-Mail:Marital Status:Select OneSingleMarriedDivorcedWidowedIf married, how many years?List the Age, Name, DOB, and Relationship of all members currently living in the household.*Please list what you consider to be the family's proudest achievements/contributions to the community. Does the person/family you are nominating have any military experience? If yes, please describe and include dates.Nominating Party's Information:Name:Home Address:City:State:Zip:County:Home Phone:Work Phone:Cell Phone:Email:Relationship to Family:IMPORTANT - Tell us why this family is a deserving Sandy Victim.Please summarize the CURRENT situation and how it affects family members and their home life. What makes them deserving? What makes the situation unique? How has the nominee affected your life? (No more than 300 words, please use the back if necessary.)Why does the roof need to be replaced? Is the roof currently leaking?Other than the roof, what top FOUR repairs need immediate attention?Upload a Picture:Program Requirements, Consents and Releases:
If your nominee is selected, you may be filmed, videotaped and photographed. Your name,image and likeness may be used in, or to publicize, East Coast Roofing Corp. By signing below, you authorize East Coast Roofing Corp. to use name, information and likeness for promotional purposes and hereby waive any rights of privacy inconnection with this program and certify that all information stated by you on this Application Form is true.
i. I am not an employee of East Coast Roofing Corp., Inc., or an immediate family member of the owner.
ii. My name, voice, actions, and likeness may be recorded on audiotape, videotape or otherwise.
iii. I agree to keep strictly confidential all information about the Program that I acquire during the participant selection process and/or my participation in the Program.
iv. If my nominee is selected as a participant, East Coast Roofing Corp.,, Inc., has no obligation to broadcast or exploit the Program.
v. I will appear on camera if requested and tell why I nominated the winner, why they deserve this, why they need this and how it will help their family if they get this.
I further understand and agree to the following:
1. If my nominee is selected, as a participant I will execute all waivers and release agreements required by the East Coast Roofing Corp. Inc.
2. The selected nominee will execute all waivers and release agreements required by East Coast Roofing Corp.,Inc.
3. Applications will only be considered if they are complete. All materials you send (including videotape and photos) will be retained by East Coast Roofing Corp., Inc. and shall become their property. They will not be returned to you whether or not your nominee is selected as a winner. Any expenses you incur during the application process including postage, shipping, material preparation (video, photos, etc.) are your sole responsibility. East Coast Roofing Corp., Inc. will not reimburse you for these expenses. Only one entry per nominator is allowed. All decisions of East Coast Roofing are final.
Unfortunately, we will not be able to verify that we have received your application.
We are not responsible for lost applications.
I authorize East Coast Roofing Corp., Inc., to investigate, access and collect information about me, about any of the statements made by me in my application, any supporting documents and any other document that I have signed or do sign in connection with my application to be selected a participant in the Program any other written or oral statements I make in connection therewith, and hereby waive all rights of privacy or confidentiality that I might otherwise have such information. I acknowledge and agree that any such information obtained by East Coast Roofing and Siding pursuant to this paragraph or otherwise may be used for purposes of selecting participants in the program, and may be described or otherwise related IN and in connection with the program,including, without limitation, in advertisements, promotions, publicity, marketing, merchandising, and in any other manner.
East Coast Roofing Corp. Inc. does not discriminate on the grounds of age, Ethnic or national origin, nationality, language, religion, belief, opinion, health, disability, or sexual orientation.
I HEREBY CERTIFY THAT ALL OF THE INFORMATION PROVIDED ABOVE AND IN THIS APPLICATION IS
TRUE AND COMPLETE. I UNDERSTAND THAT ANY FALSE STATEMENT OR MATERIAL OMISSION BY ME
MAY LEAD TO THE DISQUALIFICATION OR MY NOMINEE FROM PARTICIPATION IN THE PROGRAM
AND/OR THE PARTICIPANT SELECTION PROCESS FOR THE PROGRAM. NO PURCHASE IS
NECESSARY TO SUBMIT A NOMINATION OR RECEIVE AN AWARD.
Electronic Signature (Print Name):