Are you an individual or a corporation?
I am an individual purchasing award statuette(s) for myself.
I am a corporation purchasing corporate commemmorative awards that will remain in the legal possession of the corporation.
I am a corporation that is paying for an individual to receive award statuette(s) that will remain in the legal possession of the individual and not the corporation.

Name of Individual to Appear on Award (required):
Do not name more than one individual.  You can complete another form for another individual after completing this one.

Name of Award Category:
Do not name more than one award category.  You can complete another form for another award category after completing this one.

Name of Nominated Work:
Do not name more than one nominated work.  You can complete another form for another nominated work after completing this one.

Name of Corporation to Appear on Award (required):
Do not name more than one corporation.  You can complete another form for another corporation after completing this one.  The corporation should be a publisher or developer.

Shipping Instructions for Award:

Payment Options

I am sending a check for $250 per award statuette, payable to NAVGTR Corp.
I am making an electronic payment to NAVGTR Corp.
I have already paid for each award statuette.  My password is:

Other Codes:

Your E-mail Address: Phone:

Publisher: Developer:

Terms and Conditions:

I will accept this award and request that it be shipped to the above address.  I agree not to sell, trade, or otherwise exchange this award during my lifetime.  I also agree to return this award to NAVGTR Corp. in the event that I would otherwise dispose of this award.  I grant permission to use my name and likeness for promotional purposes.  By accepting this award, I am confirming that I performed work directly and substantially related to this award category (or that I represent a corporation receiving a commemorative award that will remain in the possession of the corporation).  I understand that NAVGTR Corp. will follow the entry rules, limitations, and procedures described in the Official Entry Form & Rules page, and I will provide the official game or product credits as proof of my eligibility if NAVGTR Corp. is not in possession of them.  I understand that the Academy reserves the right to investigate, seek further documentation to support, and/or specifically reject a partys determination of any individual as an eligible award recipient based on the appropriateness of the relationship between the individuals credited title and the category of the nomination, and other factors.  In the event that a rejection occurs, the fees associated with each rejected individual will be refunded.  I understand that other team members may also be eligible to receive their own awards for this category.  I agree to hold harmless the NAVGTR Corp. from any and all direct or indirect claims, actions, suits, or liabilities arising out of or in connection with the actions directly or indirectly related to the certification process.

Paste the terms above into this box and then check the following box to indicate that you accept these terms.
I accept these terms.

Name of Person Completing This Form:

Signature of Person Completing This Form:
i.e. If your name is Sha Mulan, type /Sha Mulan/ to provide an electronic signature.

Date of Signature: MM/DD/YYYY