Claim Submission Form

You must fill out a claim to receive the cash payout for our promotional offer.
Tips to a successful claim: Fill out ALL fields. Make sure the surveys you submit are on the approved list. Make sure you do the
correct number of surveys for your country of residence. This number changes daily, so be sure you know what it is today.
We pay via PayPal only.

First Name  
Last Name  
E-mail  
PayPal E-mail.  

Select your country of residence from the drop down menu:

 

Survey 1 Name (Must match our list)

 

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Survey 2 Name (Must match our list)

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Survey 3 Name (Must match our list)

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Survey 4 Name (Must match our list)

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Survey 5 Name (Must match our list)

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Survey 6 Name (Must match our list)

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Survey 7 Name (Must match our list)

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Survey 8 Name (Must match our list)

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Survey 9 Name (Must match our list)

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Survey 10 Name (Must match our list)

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Survey 11 Name (Must match our list)

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Survey 12 Name (Must match our list)

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Survey 13 Name (Must match our list)

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Survey 14 Name (Must match our list)

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Survey 15 Name (Must match our list)

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Survey 16 Name (Must match our list)

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Survey 17 Name (Must match our list)

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Survey 18 Name (Must match our list)

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Survey 19 Name (Must match our list)

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Survey 20 Name (Must match our list)

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