Frozen Veggie $100,000 Sweepstakes

Name and address:

Last Name:

First Name:

        Street:

           City:

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   Zip code:

Password:

What are you: Male Female

Annual household income: 

Indicate your favorite frozen vegetables:

Broccoli Cauliflower Corn Peas Spinach String Beans

Other:

  

Note: This is a sample form only. You cannot submit the information because a valid e-mail address has not been specified.

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