RTV6 - Dial One Contest Form

ALERT

Officials name Waynesville suspect

Some Hoosier families are without heat in their home and suffer from cold winter days.

RTV6 and Dial One Hour heating and Air Conditioning are teaming up to help.

Dial One Hour will donate and install a new heating system for Indiana families in need.

Watch for heart warming results on RTV6. Please fill out the form below for a chance to WIN!

Contest Rules

Dial One Hour Essay Entry Form

*Please fill out all fields.

This field is mandatory.

Nominee's Name:

This field is mandatory.

Nominee's Address:

This field is mandatory.

Nominee's City:

This field is mandatory.

Nominee's State:

This field is mandatory.

Nominee's Zip:

This field is mandatory.

Nominee's Day Phone:

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Nominee's Evening Phone:

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Property Type: Own Rent Lease

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Is nominee active in his/her community? Yes No

This field is mandatory.

In what way is nominee active?

This field is mandatory.

Is nominee the head of the household? Yes No

This field is mandatory.

Why do you believe this person qualifies?

This field is mandatory.

Do any medical conditions apply?

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Your Name:

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Your Address:

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Your City:

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Your State:

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Your Zip Code:

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Your Phone Number:

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Your Email Address:

Indianapolis , IN

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