Index
Helping Out Locally Order Form
Company Name:
Contact First Name:
Contact Last Name:
Contact Email:
Contact Phone:
Contest Name:
Desired Contest Start Date:
Payment Information
First Name:
Last Name:
Address:
City:
State:
--- States (Provinces Below) ---
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
--- Canadian Provinces ---
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
--- Australian States/Territories ---
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Postal Code:
Country:
USA
CAN
AUS
;
Credit Card Number:
Exp. Mth.:
January
February
March
April
May
June
July
August
September
October
November
December
Exp. Yr.:
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
CVV:
Coupon Code:
Terms of Service
Check this after reading below.
I attest that by filling out and submitting this form, I am purchasing one Online Access Helping Out Locally contest. Upon submission, I understand that my card will be charged $1000 for the initial contest. Furthermore, I understand that I will be responsible for continual engagement with the program contestants.
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