WARRANTY OF ELIGIBILITY AND

LIABILITY AND PUBLICITY RELEASE

The undersigned represents and warrants to Henry Schein, Inc. (HSI) (Sponsor), the following
as a condition of acceptance of the contest prize awarded in 2014 Digital Impression Questionnaire.
1. I am a legal United States or District of Columbia dentist, age 18 years old or older or the
age of majority in my state of residence, whichever is greater at the time of entry and I am not a residents of
Puerto Rico or a dentist licensed to practice medicine in Illinois, Massachusetts, Michigan, Minnesota, New
Jersey, Puerto Rico, Rhode Island or Vermont.
2. I am not an employee of HSI or its affiliates, subsidiaries, parents, advertising, promotion
and fulfillment agencies or member of the immediate family or household of each. Immediate family
member is defined as a parent, sibling or any person residing in same household as employee.
3. I hereby agree as a sweepstakes entrant to abide by all Rules and Regulations of The 2014
Digital Impression Questionnaire and to be bound by the official rules and the decisions of the Sponsor,
(including but not limited to eligibility determinations) which are final and legally binding in all respects.
4. I hereby agree that all expenses, taxes and costs associated with acceptance and use of
prizes, including but not limited to, if applicable, completion of a W-9 form provided by HSI are the
obligation of the winner.
5. I hereby authorize Sponsor, to use my name, voice, photograph likeness and/or testimonial
for advertising and promotional purposes in connection with this promotion without additional
compensation, unless prohibited by law.
6. I hereby agree, by accepting this prize, to hold Sponsors, harmless against any and all claims
and liability arising out of use of this prize and agree to release Sponsors, and its employees and agents from
any and all liability, loss, damage or injury resulting from participation in this promotion or awarding,
receipt, possession use and/or misuse of any prize awarded herein and acknowledge that Sponsor, and its
employees and agents have neither made nor are in any manner responsible or liable for any warranty,
representation, or guarantee, express or implied, in fact or in law, relative to any prize.
7. The federal government imposes certain restrictions on, and requires public reporting of,
transfers of value to a practitioner. Accordingly, for certain transfers of value we require your agreement
and certification below that your practice is neither enrolled in nor bills any federal health care program (e.g.,
Medicare, Medicaid, Tricare, Childrens Health Insurance Program) for dental, oral surgery or
pharmaceutical services. Accordingly, you agree and certify that to your knowledge neither your practice
nor any of your patients are enrolled in or reimbursed by federal programs for such services, and that if at
any time such practice status changes, you will promptly notify us in writing.

Agreed and certified:


____________________________
Name:
Address:
City, State, Zip:
Date: