SOUNDTRACK TEiii§SŒ MOS 'C A FILM BY KEN BURNS THE …

Have you collected at least 5 stamps? Fill out this form and send it along with your passport by certified mail to the address listed below. Once we receive it, we’ll package up your souvenirs and mail them to you with your passport. This process may take around 6 – 8 weeks, but we promise it’ll be worth the wait.

By mailing in this form, you agree to having

read and accepting the terms & conditions.

Wm. Snodgrass/Tennessee TowerAttn: TDTD - Ken Burns Passport312 Rosa L. Parks Ave., 13th FloorNashville, TN 37243-1102

First Name Last Name

Address

City, State Zip Code

Phone Number

I am not a State of TN employee.

*Your taxpayer ID or social security number is required to comply with IRS reporting requirements. Since you are receiving an item of value, you may be subject to IRS reporting information (i.e. reporting on a Form 1099-MISC). The State will issue a 1099-MISC form to you, if you have been paid at least $600.00 in rents, services, prizes and awards or other income payments.

SSN or Tax ID Number*