page 1 of 2 OFFICIAL ENTRY FORM

TO ENTER: 1. An eligible entry consists of: a) Page 1 of this form completed and signed by the student's parent/guardian. b) The artwork submission completed on page 2 of this form. Both pages must be submitted together. 2. For legibility purposes, we encourage you to complete the form on your computer as the fields are editable. 3. Once complete, please print out the form on a light colored 8.5"x11" sheet of paper. Be sure to print on 2 separate pages. 4. Make sure the student's parent or guardian has signed the form on the appropriate line. The entry will not be considered without this signature. 5. Mail your form to the address below. Note all entries must be mailed by March 20, 2012 so please allow enough time.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN OF STUDENT ENTERING THE CONTEST.

All fields are required. SUPPORTING STATEMENT: Please tell us briefly how your doodle expresses the theme STUDENT’S NAME “If I could travel in time, I’d visit...” (max 50 words): ▼

STUDENT’S AGE GENDER: MALE FEMALE

PARENT/GUARDIAN’S NAME

ADDRESS

CITY STATE ZIP

PARENT/GUARDIAN’S PHONE NUMBER

PARENT/GUARDIAN’S EMAIL ADDRESS Entries received without this COMPLETED Entry Form will not be accepted or judged and will be disqualified. Entries must be FULL-TIME mailed by March 20, 2012 in order to be considered. SCHOOL NAME Mail entry (packaged carefully so it won’t be damaged), with proper If student is homeschooled, please note this in the school name field and you will not need to complete the remaining school related fields. postage so that it’s mailed by March 20, 2012 to:

FOR REGULAR MAIL: SCHOOL ADDRESS Doodle 4 Google PO Box 9112 Plainview, NY 11803-9112

FOR OVERNIGHT DELIVERIES: Doodle 4 Google SCHOOL PHONE NUMBER 35 Pinelawn Road, Suite 207W Melville, NY 11747 I agree to receive e-mail communications regarding Doodle 4 Google. (not required) Before mailing, make sure all fields on the form are complete (including supporting statement and parental signature) and artwork By signing below, I acknowledge that I am the parent/legal guardian of the entrant is done on the second page of this form. Both pages must be and hereby give my permission for him/her to enter the Doodle 4 Google 2012 submitted together in order for an entry to be complete. Contest. I certify that the entrant is enrolled in a private, public or home school (grades K-12) and is a legal resident of the U.S. I have read the Official Doodle For more details and Official Rules, 4 Google Contest Rules and acknowledge that this entry is both bound by and please visit www.google.com/doodle4google adheres to them.

PARENT/LEGAL GUARDIAN SIGNATURE DATE OFFICIAL CHILD’S FULL NAME: ENTRY STATE: GRADE GROUP: Grades K-3 Grades 6-7 Grades 10-12 FORM Grades 4-5 Grades 8-9

▼ TITLE OF YOUR DOODLE: USE THIS SPACE TO CREATE YOUR GOOGLE DOODLE:

page 2 of 2