A Division of Albemarle Dermatology Associates, LLC
Facial Rejuvenation Give Away Entry Form
Applicant’s First Name: _________________ Middle Initial: ______ Last Name: ________________________________
Email Address (if available): __________________________________________________________________________
Phone Numbers: Home: ______________________ Work: ______________________ Cell: _______________________
Street Address: ____________________________________________________________________________________
City: _________________________________________________ Zip:_______________________________________
Date of Birth: _____________________________ Gender: Male or Female (circle one)
Name, if different from applicant: ______________________________________________________________________
If not self, relationship to nominated applicant: ____________________________________________________________
Please describe why you are a deserving candidate or why your nominee is a deserving candidate.
Attach your response in 200 - 400 words on a separate sheet.
Include two recent, clear pictures of the applicant’s face.
One of the pictures must include at least some of the torso.
(We will return the photos if requested to do so on the back and if you include a stamped, self-
Please check the way you first learned about our Makeover Giveaway:
___ Daily Progress Insert: The Guide to Cosmetic Dermatology
___ C’ville Weekly Insert: The Guide to Cosmetic Dermatology
___ Signature Medical Spa Website
___ Internet Search Engine
___ Friend or Family Member
___ Albemarle Dermatologist or Signature Practitioner
___ Other: __________________
Thank you for your application!
By submitting your registration information, you indicate that you agree to the Terms of Service.
1. All contestants must be permanent resident of VA and must provide Signature Medical Spa with a valid form of identification and Social Security number satisfactory to Signature Medical Spa management. Disclaimer:
2. All contestants must be at least 18 years old to be eligible to participate in the giveaway contest.
3. Entry forms may be mailed to:
Signature Medical Spa Facial Rejuvenation Give Away, 3350 Berkmar Drive, Charlottesville, VA 22901.
All entries become property of Signature Medical Spa and will not be returned. Signature Medical Spa
reserves the right to retain any or all contest materials for any reason that Signature Medical Spa deems
necessary to the completion of the giveaway contest, or reasons relating to publicity and/or advertising.
4. As a condition of entering the giveaway contest, applicants must agree that upon winning they will
consent to the use of their name, likeness, and all verbal and written communication with Signature
Medial Spa for publicity purposes.
5. All prizes are non-transferable and are not redeemable for cash.
6. Signature Medical Spa, assumes no liability for liability, damages, situations, repairs or incidents arising from
any aspect of any prize awarded in any giveaway contest. As a condition of entering the giveaway contest,
participants may be required, upon winning, to sign a release form and affidavit of eligibility to claim their prize.
Failure to do so will result in forfeiture of the contestant’s right to claim or receive the prize.
7. All giveaways and contest are void where prohibited by law. All local, state and federal regulations apply.
8. Although Signature Medical Spa will make reasonable efforts to conduct its giveaway contest substantially
as announced or advertised, Signature Medical Spa reserves the right in extraordinary situations to change
or modify the rules of its giveaway as exigent circumstances may require. In such cases, Signature Medical
Spa will amend the rules for its giveaway and broadcast the amended rules as promptly as possible.
In such case, the giveaway will be conducted in accordance with the amended rules.
9. A copy of these rules are available during business hours at Signature Medical Spa, 3350 Berkmar Drive, Charlottesville,