 Prize Claim for Corrupt Interactive Inc. and groupmediaCI Online Entertainment Please fill out the Form Completely as this form is the most important step to receiving your prize in a timely manner. Game: __ Top Shift __ Midnite Challenge __ MC Boost Mode __ Street Heist Login name: ____________________________________________ Display name that round: ________________________________ Posting and Prize Claim Date: ______________________________________ Finishing Position: ________________________________________________ Which Game: ____________________________________________________ Which Game Round (Round ID Number): ______________________________________________ Prize Being Claimed: ______________________________________________ Last Prize Won at Corrupt Interactive Inc: _____________________________ Email address: __________________________________________ Paypal email address: _____________________________________________ Home Address (Must Match Game Registration Address): __________________________________________ __________________________________________ __________________________________________ __________________________________________ Telephone Number: ______________________________________ Are you claiming credits instead of your cash prize? Yes/No _________ Are you claiming Cash instead of your tangible prize? Yes/No _________ If yes, which staff member at groupmediaCI OK’d this claim? __________________________________________________________ Comments: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Please enclose the following when mailing your claim sheet to us: 1 Corrupt Interactive Inc. Prize Claim Sheet (Must be Legible and Signed) (Midnite Challenge, Street Heist, Top Shift, or MC Boost Mode) 1 International Money Order for $25.00 for Prize Shipping in North America. (Flat Fee, Does not include duties or tax’s.) (If applicable, read FAQ section and Forums) I, _____________________ am claiming my prize for TS / MC / MCBM / SH (Circle One) in the __________ Game Period (Game ID #). My login name is ___________ and I finished in __________ Place. My telephone number is __________. I understand that it will take between 3-6 months for me to receive my prize, and that it will be shipped via United Parcel Service or will be posted in my Paypal account. I have read all the terms and conditions on the web sites regarding prize claims and have also read the frequently asked questions regarding prizes and prize shipping. I also understand that Corrupt Interactive Inc. will not ship a prize to an incorrect address that is not in our Gaming Database, and reserves the right to revoke a prize if a member is caught cheating or using any fraudulent means of credit purchase or fraudulent game-play as determined by us within our audit period. I have read and understood all Rules and Regulations in regards to prizes, shipping, game play and all rules in regards to all Corrupt Interactive Inc. and groupmediaCI games online and I understand that the Terms of Service are in effect as long as you are a member of the games and are using the sites. I have also filled out this Form Completely and included my International Money Order (if applicable) for Prize Shipping Payable to Corrupt Interactive Inc. Signed: ______________________ Printed Name: ______________________ Date Sent: ______________________ |
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