Prize NUMBER Registration Form for:

Empire Chevrolet
1931 US Hwy 421 N
Wilkesboro, NC
800-580-9116
Event Dates:
8/19-23 & 8/26-30

Please fill out the following form to register your winning number.
All fields must be filled out correctly.
All fields marked with an asterix * are required.

*First Name:
*Last Name:
*Address 1:
Address 2:
*City:
*State:
*Zip:
*Area code and Phone Number:
E-mail Address:
Preferred Contact:
*Your Prize Number:
Optional Information
Are you looking for a New or Used Car?:	New Used
What make of car do you own?:
Model:
Year:
Current Payment:
Please only submit your registration once. Terms and conditions apply. refer to the mailer/advertisement associated with this event for details. information entered on this form will be used for direct marketing purposes.

Terms and conditions apply. refer to the mailer/advertisement associated with event for details.