Prize - Painaway Belts

Please enter me in your competition for one of
three possum belts being given away in
your next draw on June 30 2020

Magazine/Paper*
Publication date*
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Mobile
Back Pain – Have you ever suffered from back pain?
- Never
- Occasionally
- All the time
Email*
Age
* Please give the Name & Date of the publication in which you saw this offer

** Please include your Email address (if you have one) for quickest notification should you be a winner