Free 53848.pdf - Indiana

IDEM POSTER CONTEST ENTRY
State Form 53848 (1-09)

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Indiana Department of Environmental Management INSTRUCTIONS: 1. Complete all lines of the entry form. 2. Sign and date the release section. 3. By submitting your entry you are indicating that you have read and agree to all contest rules. ENTRY INFORMATION
First and Last Name of Artist First and Last Name of Sponsoring School Contact Address of Sponsoring School (number and street, city, state, and ZIP code) Phone Number of Sponsoring School Contact (with area code) Name of Sponsoring School Sponsoring School Contact E-mail Address

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Poster Dimensions (XX to XX)

Title for Poster

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Artist's explanation of the intended key message being conveyed in the created work. (maximum of 100 words)

RELEASE SECTION I hereby give the Indiana Department of Environmental Management (IDEM) the right to use this poster entry in any, advertising/promotional materials (print, electronic, etc.), and exhibit and display at all IDEM-hosted/sponsored events including but not limited to digital reproductions, with credit given to the artist. . Entries may not be copyrighted. IDEM reserves the right to allow the use of the materials by third parties. I hold IDEM harmless from any and all liability that might arise out of or result from the foregoing use. Your entry signifies that you will abide by all rules, including that you will provide a true signature if your poster is selected in the contest.
Signature of Sponsoring School Contact (RETAIN A COPY OF THIS FORM) SIGNATURE WILL BE REQUIRED IF YOUR ENTRY IS SELECTED Date (month, day, year)

Printed Name

Are you at least 18 years of age?

Yes
Are you an Indiana resident?

No No

Are you a U.S. Citizen or permanent legal resident?

Yes

No

Yes

Parent's Name (Print)

Parent's Signature (If applicant is under the age of 18)

Return Completed Entries to: By Mail MUST PUT THE IMAGE AND THE ENTRY FORM ON CD: By e-mail YOU MUST E-MAIL THE FORM AND THE IMAGE: Entries may be dropped off between 8:15 a.m. and 4:45 p.m. Monday through Friday at: IDEM Poster Contest MC 50-03, IGCN 1313 100 North Senate Avenue Indianapolis, IN 46204-2251

[email protected] Indiana Department of Environmental Management Indiana Government Center North 100 N. Senate Ave. Rm. N1301 Indianapolis, IN 46204

See reverse for rules.

General IDEM Poster Contest Rules
Contest is administered by the Indiana Department of Environmental Management (IDEM) to solicit posters for promotional pieces that the agency does. Any photographic images must be of Indiana locations. Poster entries may not contain any type or words superimposed over the image in English or any other language. The poster entry can be in hard-copy or an electronic format. Poster entry may be sent via postal service or e-mail. Contestants must not be employed by the Indiana Department of Environmental Management. Poster entry must be the original work of the contestant. Poster entry must be the sole work of the contestant. Poster entry allows IDEM to reproduce the image in any of its promotional pieces (electronic, print, etc.) and for use in promoting other contests for the agency. A completed entry includes the poster and a completed poster entry form, which are sent via postal service or e-mailed to IDEM at the following addresses: Postal Service: IDEM Poster Contest MC 50-03, IGCN 1313 100 North Senate Avenue Indianapolis, IN 46204-2251

E-mail: [email protected] with subject line "IDEM Poster Contest"