MY CANADA, MY INSPIRATION CONTESTTo mark Canada’s 150th anniversary, the Royal Canadian Mint is inviting Canadians to design our five circulation coins for 2017. This is your chance to express what you love most about our great country—and create your own piece of history.

To enter, choose from one of the five themes listed on the next page, print the template available on mint.ca/Canada150, use it to create your design, and send it to us, along with this form, by fax or mail.

Canadians of all ages may participate in the contest. For those under the age of majority in the province in which they reside, a parent or legal guardian must consent to their entry in the contest by filling out the form and confirming that they have read and agree to the Contest Rules (available at mint.ca/Canada150) on the participant’s behalf.

PARTICIPANT’S CONTACT INFORMATION *REQUIRED INFORMATION

*FIRST NAME:

*LAST NAME:

ADDRESS:

CITY: *PROVINCE:

*POSTAL CODE: *AGE:

we require at least the first three digits

*EMAIL ADDRESS OR PHONE NUMBER:

only for participants 18 and over

PARENT’S OR LEGAL GUARDIAN’S CONTACT INFORMATION

*FIRST NAME:

*LAST NAME: 

*EMAIL ADDRESS OR PHONE NUMBER:

All personal information collected by the Royal Canadian Mint is protected under the Privacy Act. By completing this form, you consent to the collection of your personal information and that of the participant’s to allow participation in the contest. Your personal information will not be used for any other purpose.

IF PARTICIPANT IS UNDER THE AGE OF MAJORITY IN THE PROVINCE IN WHICH THEY RESIDE

PARTICIPANT’S DESIGN*SELECT THE DESIGN THEME:

DESIGN TITLE *ENTER TITLE OF YOUR DESIGN:

DESIGN DESCRIPTION The participant should explain in his or her own words what the design depicts, the inspiration behind it, and how it relates to the chosen theme.

Design must be your original work. Please note that any design that includes copyrighted material will be disqualified. For more information see the Contest Rules.

PLEASE NOTE THAT ONLY PARTICIPANTS 12 AND UNDER CAN SUBMIT A DESIGN IN

THE “OUR FUTURE” THEME

OUR WONDERS Beauty is everywhere you look. Where

do you see it? Whether you find it in our breathtaking landscape, our boundless flora and fauna or in our spectacular monuments, let Canada’s beauty inspire you to create your own story.

OUR CHARACTER Our shared values and diversity are what

define us as a nation and set us apart. Whether it’s our welcoming nature, our spirit of generosity, our joie de vivre or renowned politeness, let whatever value you value most inspire your design.

OUR ACHIEVEMENTS Canada is a country rich in outstanding

achievement. Whether it’s through exploration, invention, discovery or victory, look to our exceptional accomplishments to inspire what could be your own greatest work.

OUR PASSIONS Our passions run deep and keep us fired

up all year long. Whether you’re interested in art, sports, literature, music or food, picture what you love doing most as your coin design.

OUR FUTURE (KIDS 12 AND UNDER) We know you love to daydream about the future. What does it look like to you? Close your eyes and picture it. Whatever your vision of Canada’s tomorrow is, imagine

it on a coin in 2017!

Please take a moment to review the information you just entered and check the appropriate boxes below.

FOR PARENTS OR LEGAL GUARDIANS OF PARTICIPANTS UNDER THE AGE OF MAJORITY IN THE PROVINCE IN WHICH THEY RESIDE:

*I am the parent or the legal guardian of the contest participant, who wishes to enter the My Canada, My Inspiration Contest.

*I have read and agree to the Contest Rules on the participant’s behalf.

FOR PARTICIPANTS OVER THE AGE OF MAJORITY IN THE PROVINCE IN WHICH THEY RESIDE:

*I have read and agree to the Contest Rules.

I would like to receive occasional emails from the Royal Canadian Mint and be among the first to hear what’s new! I may unsubscribe at any time.

PLEASE BE SURE TO SEND YOUR DESIGN AND COMPLETED FORM BY APRIL 30, 2015- BY MAIL to My Canada, My Inspiration Contest, Caribou Room,

320 Sussex Drive, Ottawa ON, K1A 0G8; or

- BY FAX to 613-949-1940.

THANKS FOR ENTERING THE MY CANADA, MY INSPIRATION CONTEST!We will only contact you if your design is selected by our panel of notable Canadians. Good luck!