entry form

Name *

First Name

Last Name

Company Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date First Appeared *

MM

DD

YYYY

*

I certify that all the information above is correct and true.

Yes

*

I allow the IBO and Indie Impact Awards to use the images and videos I have provided in their own marketing and promotions.

Yes