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Bike MS: Express Scripts Gateway Getaway Ride 2012 Prize Selection Form • Please submit all unpaid pledges by October 15, 2012. • In order to receive your prize at the Awards Party, this form must be submitted by November 4, 2012. • All prizes must be claimed by January 2, 2013.

2012

STEP 1

Please complete the following information. Prizes will be available for pick up at the Awards Party in December. If you are unable to attend the Awards Party, your prize will be mailed to you. Name___________________________________________Phone_____________________________________ Address______________________________ City___________________ State_________ Zip_______________ r I would like to donate my prize back to the National MS Society, Gateway Area Chapter. (In kind receipts are available for tax purposes).

STEP 2

View the chart below to determine which prize you are qualified to receive. You may pick one prize option corresponding to your fundraising level. Please check your fundraising level and ONE prize option based on your individual fundraising total (monies received at the Gateway Area Chapter by October 15, 2012). RAISED (check one)

PRIZE (check one)

r $20,000 or more

Mission Possible Club, Trip for Four to Tour of Champions and 2012 Bike MS Jersey

r $15,000 - $19,999

Mission Possible Club, Trip for Three to Tour of Champions and 2012 Bike MS Jersey

r $10,000 - $14,999

Mission Possible Club, Trip for Two to Tour of Champions and 2012 Bike MS Jersey

r $6,800 - $9,999

Mission Possible Club and one of the below r $700 Bike Shop Certificate r $500 Gift Card r $625 Bike Shop Certificate and a 2012 Bike MS Jersey r $425 Gift Card and 2012 Bike MS Jersey

r $3,500 - $6,799

Spokes Club and one of the below r $250 Bike Shop Certificate r $175 Gift Card r $175 Gift Certificate and 2012 Bike MS Jersey r $100 Gift Card and 2012 Bike MS Jersey

r $2,000 - $3,499

r $1,000 - $1,999

STEP 3

r $750 - $999

Spokes Club and one of the below r $150 Bike Shop Certificate r $100 Gift Card r $75 Bike Shop Certificate and a 2012 Bike MS Jersey r $25 Gift Card and a Bike MS Jersey Spokes Club and one of the below r $100 Bike Shop Certificate r $25 Bike Shop Certificate & Bike MS Jersey r 2012 Bike MS Prize Jersey OR r 2012 Bike MS Bicycle Shorts

Go to www.gatewaymsbikeride.org g ‘Fundraising’ g ‘Prizes’ for more information or to see the 2012 prize jersey.

Please check one (if applicable) r S r M r L

Jersey r XL

r XL

Men’s Bicycle Shorts r S r M r L r XL r XL r XXL Women’s Bicycle Shorts r S r M r L r XL r XL r XXL

PLEASE MAIL, FAX OR EMAIL THIS FORM TO: National MS Society, Gateway Area Chapter, 1867 Lackland Hill Parkway, St. Louis, MO 63146 Fax: 314-781-1440 Some restrictions apply. Prizes are not redeemable for cash and are not cumulative, non-transferable and non-replaceable. We reserve the right to substitute prizes of equal or greater value. Participants are responsible for taxes on prizes in value of $600 or more. Please fill out a W-9 and send it in with this prize form. Call 314-781-9020 if you need a W-9.

Bike Prize Form 2012.indd 1

2/23/2012 11:35:06 AM


Bike MS 2012 Prize Form