Shop Local, Shop Small 2019

GRAND PRIZE DRAWING

REGISTER YOUR PURCHASE TO ENTER THE GRAND PRIZE DRAWING! Thank you for supporting Small Business Saturday and registering your purchase. PLEASE CLICK SUBMIT BUTTON AT THE END TO COMPLETE YOUR ENTRY.

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* 1. Enter 4-Digit Ticket Code

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* 2. Your Contact Info:

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Mobile Number

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* 3. Select the participating small business where you made your purchase.

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* 4. How long have you been a customer of this small business?

This is my first purchase

Less than six months

Six months to a year

1 - 2 years

3 or more years

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* 5. What is the date of purchase on your receipt?

Date of Purchase

Date

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* 6. What is the the total amount of your receipt?

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* 7. Did your purchase include any of the following? (choose all that apply).

Gasoline

Cigarettes

Lottery Tickets

Prescription Products

Beer, Liquor (alcohol)

None of the above