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To: Swiss Chalet Rotisserie and Grill, a Division of Cara Operations Limited (the “Sponsor&rdq... - page 1 / 3

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Swiss Chalet‟s Dip „n Win Peel and Reveal Promotion 2011 (the “Contest”) DECLARATION AND RELEASE FORM

To: Swiss Chalet Rotisserie and Grill, a Division of Cara Operations Limited (the “Sponsor”)

INSTRUCTIONS TO POTENTIAL WINNER: Please read this entire Declaration and Release Form (“Declaration and Release”) carefully and complete, legibly, all of the areas below requiring you to submit information. Sign this document where indicated below (and have your parent/legal guardian complete the relevant section below if you are under the age of majority in your province/territory of residence) and mail your completed Declaration and Release, along with your original winning Dip „n Win Promotional Sauce Cup Label (the “Label”) to: “Swiss Chalet‟s Dip‟n Win Peel and Reveal Promotion 2011”, PO Box 3050, Station D, Etobicoke, ON M9A 4X5. We suggest you keep a copy of the Label for your records. We strongly recommend sending all materials by REGISTERED MAIL, return receipt requested, and keep a copy of the label and Declaration and Release Form for your records.

YOU MUST COMPLETE ONE DECLARATION AND RELEASE FORM FOR EACH PRIZE YOU ARE CLAIMING. ALL PRIZE CLAIMS MUST BE RECEIVED BY NO LATER THAN JULY 31, 2011 TO BE ELIGIBLE.

Potential Winners Personal Information:

Name:

______________________________

A d d r e s s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

C i t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Province/Territory:

____________________

P o s t a l C o d e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Day Phone:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Evening Phone:

_______________________

Date of Birth (mm/dd/yy): ______________

Address of the Swiss Chalet Restaurant where the winning label was received: ___________ ___________________________________________________________________________

SKILL-TESTING QUESTION

If you are eligible to win one of the prizes listed, you will be contacted by a representative of Sponsor, who will administer a time-limited mathematical skill-testing question via phone at a mutually-convenient time, which you must answer without assistance of any kind, whether mechanical or otherwise.

I, the Potential Winner identified above, am the potential winner of the following prize (the “Prize”) in the Contest (please select one):

  • 2012 Brute Force 750 4x4i EPS ATV from Kawasaki (ARV: $11,799)

  • 2011 Subaru Legacy 2.5i Sedan Prize from Subaru Canada, Inc. (ARV: $26,815)

  • 1-Day Car Rental from Discount Car & Truck Rentals (ARV: $48)

  • 3-Day Car Rental from Discount Car & Truck Rentals (ARV: $144)

  • 7-Day Car Rental from Discount Car & Truck Rentals (ARV: $288)

  • Tom Tom GPS (350M) (ARV: $150)

  • “The Lord of the Rings”: The Extended Motion Picture Trilogy on Blue-ray from Alliance Films

(ARV: $112)

  • Sony HDD Camcorder (DCRSR88) (ARV:$480)

  • Sony Wireless Headphone (MDRF925RK) (ARV: $120)

  • $100 HMV Gift Card

  • Air Canada Vacation Trip to Turks & Caicos OR Jamaica (ARV:$7,500)

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