2025 Circle K Great Lakes

WINNER/PRIMARY'S INFORMATION

Note: If you are applying for a passport, please include your name as it appears on your passport application.

PLEASE NOTE: The current processing time for new applications is 4 to 6 weeks from the time the application is received. If you choose to expedite the process for an additional fee, the expedite process time is 2 to 3 weeks from the time the application is received. Additional time is required for mailing to/from the Passport Office.

First Name (as it appears on your passport)

Middle Name (as it appears on your passport)

Last Name (as it appears on your passport)

Preferred First and Last Name on Name Badge

Birth Month:

Birth Day:

Birth Year (YYYY):

Gender:

Do you have a passport?

Company Name:

Country:

Mobile Phone:

Email Address:

Emergency Contact's Name:

Emergency Contact's Phone

Do you have dietary restrictions?

Are you bringing a guest? (All guests must be at least 18 years old.)

The below information will be used for mailing your pre-travel packet.

Address 1:

Address 2:

City:

State:

Postal Code:

AIR TRAVEL PREFERENCES

TSA PreCheck Number:

EXCURSION SELECTION

For Tuesday, November 11, Circle K Great Lakes is covering one excursion per person. You can purchase additional excursions when you arrive in Dominican Republic at the Circle K Great Lakes Ambassador Club Trip Hospitality Desk.

Please select an excursion to view its description.

Excursion Selection - November 11

HOTEL ACCOMMODATIONS

W Punta Cana

Carretera Uvero Alto Higuey,

La Altagracia, Dominican Republic, 23000

Website

Do you require Hotel accommodations?

GENERAL RELEASE & AGREEMENT

I am participating in a class, or other organized event on Circle K Stores, Inc. property. I understand that this is not a work-related event, nor am I required to attend by Circle K Stores, Inc.

In consideration for the use of W Punta Cana, La Altagracia, Dominican Republic for this event, I hereby release Circle K Stores, Inc., its Officers, Directors, Managers, Employees or other Agents, collectively Circle K Stores, Inc. from any liability, real or perceived, which may arise as a result of my participation in this event. I understand that I am voluntarily assuming the risk of any potential accident or injury, and accordingly, agree not to assert against Circle K Stores, Inc. any cause of action which may arise from such injury or accident.

CIRCLE K INCENTIVE TRIP POLICY

Policy

Circle K believes that it is important to recognize and reward the top performing individuals that go above and beyond in achieving fundraising goals. Circle K has developed an incentive trip as a way to recognize and thank these Circle K employees.

Procedures

1. Each year a special destination is selected for the incentive trip, typically including:

5-7 night stay at an exclusive resort or on a cruise ship
Airline round-trip travel
Recognition events
Transportation to and from the hotel and airport

2. All incentive award participants can also bring one individual with them on the trip who is at least 18 years of age (family member, friend, etc.)

3. The total expenses related to the annual incentive trip are estimated to be $3000 per person for each individual who attends the incentive trip. The estimate may change due to actual trip costs and the number of participants. Circle K determines this amount by taking the total of the direct cost related to the incentive trip and dividing that number by the participating attendees. Circle K will communicate to all participants in advance of any incentive trip to anticipate expenses for each event including any significant cost increases for any future incentive trips planned.

4. The cost of the trip for employee and guest is considered taxable income to the employee. The taxable income will be grossed up to cover the employee's federal and state taxes and will be reported on the W-2.

Requirements | Pertaining Only To Circle K Employees

1. If a Circle K employee is awarded a trip, the employee must use his/her accrued vacation when requesting time off for the occasion.

2. If a Circle K employee who is selected to participate in the incentive trip is not able to attend, for personal reasons or other business priorities, he/she may decline participation. There will be no monetary value paid in lieu of the incentive trip option to anyone who declines participation. It is necessary that the employee who declines the invitation provide as much notification in advance to Circle K Senior Management. As a courtesy, such notification is essential in order to keep incentive trip expenses down. There will be no replacement if this does occur.

3. Circle K's Great Lakes Division Vice President based on his sole discretion will determine who will be invited to participate in the incentive trip.

4. If a Circle K employee wants to take another Circle K employee, VP of the Great Lakes Division needs to approve. The guest Circle K employee needs to be a relative, spouse, or significant other/partner. No exceptions.

Exceptions: NONE

I agree to the terms and conditions outlined above.

VERIFICATION

Please verify your responses before submitting them:

Once you click submit, you will be re-directed to register your guest information, if applicable.

WINNER INFORMATION

MAILING ADDRESS

AIR TRAVEL PREFERENCES

EXCURSION SELECTION

HOTEL ACCOMMODATIONS

POLICY