CLASS MEMBER CLAIM FORM

You are entitled to a certificate per household for a free one-gallon jug of either a) Nursery® Water; or b) a non-fluoridated DS Waters purified water product if you purchased Nursery® at any time from February 21, 2004 to date and made the decision to purchase because of the statements or information provided in advertisements, labeling, and in store displays for Nursery®, including nurserywater.com. 

If qualified, you may obtain only one certificate per household by completing and submitting this form.   The certificate will be mailed to the name and address you provide below and may be redeemed at any retail store that carries the specified DS Waters’ products and accepts such certificates.

ALL FIELDS REQUIRED

Please indicate which product certificate you are interested in obtaining:

Nursery® Water Non-fluoridated DS Waters’ brand purified water
First Name:
Last Name:
Address:
Country:	United States
City:	State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code:
Email Address:
Verify Email Address:
How many children are in your household:
I purchased Nursery® Water during the period of February 21, 2004 to date based on viewing the following: (check all that apply)

12 Meses Magazine	American Baby First Year of Life	American Baby Magazine
American Childbirth Guide	Child Magazine	Espera Magazine
NewAmerica FSI	Our Kids San Antonio Magazine	Parents Healthy Kids brochure
Parents Magazine	Plum Magazine	Ser Padres Magazine
Door hanger	www.nurserywater.com, version posted 2006 to present
Other (please specify):
I have read and agree to the rules and privacy policy.