STAND AND DELIVER Entry Form

Merz Aesthetics, Inc., exclusive distributor of Asclera® (polidocanol) Injection, along with an advisory panel of women who were selected for their significant abilities to STAND AND DELIVER, is conducting a nationwide search for inspirational women who are changing their communities one day at a time through support of a 501(c)(3) non-profit organization.

To nominate a neighbor, colleague or friend, simply complete the entry form below by January 15, 2012.

After the submission period closes, the advisory panel will select three women who STAND AND DELIVER, and their stories will be featured on this website, giving them national recognition for their causes. From February 20 through April 15, 2012, you'll have the chance to cast your vote for the finalist you feel best STANDS AND DELIVERS for her cause.

One lucky winner, determined by your votes, will receive $10,000 from Merz Aesthetics and Asclera® to support her favorite charity, as well as a professional beauty makeover. For more information about the contest rules and entry criteria, see the Terms and Conditions.

*Denotes required field. Must be 18 or older to participate.

Tell Us Who You Are

Your First Name: *
Your Last Name: *
Date of Birth: *
Your Email: *
Confirm Your Email: *
Your Phone Number: *
Best Time To Be Contacted: *
Relationship to Nominee: *

Tell Us About Who You Are Nominating

Nominee's First Name: *
Nominee's Last Name: *
Date of Birth:
Tell Us How She STANDS AND DELIVERS For A Cause
(in 200 words or less): *
Upload a picture of your nominee: *

* I certify that I am 18 years of age or older.

* I certify that by nominating a woman for the STAND AND DELIVER program, I will help Merz Aesthetics, Inc. get in touch with the nominee via email and/or phone, to the best of my ability.

* By submitting my information I agree to the STAND AND DELIVER Terms and Conditions , and that a representative of Merz Aesthetics, Inc. can contact me. I understand my information will be governed by this site's Privacy Policy and Terms of Use.

Yes, I am interested in receiving updates and news regarding the STAND AND DELIVER program and Asclera®. By checking this box and clicking submit, I agree to the personal information Agreement and Disclosure.

Agreement and Disclosure

I give Merz Aesthetics, Inc. ("Merz") permission to send me future communications about STAND AND DELIVER and Asclera® (polidocanol) Injection. Merz may also send me other information, including relevant news, or request my feedback in confidential consumer surveys.

Merz respects your privacy, and you will always be given the opportunity to stop these communications. Please click here to read our privacy statement for information on how we handle your information. We will not sell or transfer your name, address, or e-mail address to any other party for their own marketing use. Thank you.

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