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

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Dated at

___________________________

this

__________

day of

_______________, 2011.

____________________ Signature

_______________ Witness Signature

_________________ Name (Please Print)

______________________ Witness Name (Please Print)

TO BE COMPLETED IF POTENTIAL WINNER IS UNDER THE AGE OF MAJORITY IN HIS/HER JURISDICTION OF RESIDENCE

I, the undersigned, represent that I am the _____________________________ (Mother, Father, Legal Guardian) of the Winner named above, and as such I am fully authorized and entitled to enter into this agreement on his/her behalf.

_____________________________ ADULT WITNESS SIGNATURE

Name:

____________________________ SIGNATURE OF PARENT OR LEGAL GUARDIAN Name:

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