Fill in your details below to sign up for ongoing promotional communications from the LISTERINE® brand. You also have the opportunity to sign up to participate in the personal trial programme whereby you can receive samples of LISTERINE®. Please read and select the appropriate opt in. You will not be able to subsequently opt in to receive communications after you submit this form. First Name * Last Name * GDC * Email Address * Job Title * Dentist Dental Hygientist Dental Nurse Dental Therapist I agree to being contacted by email by the LISTERINE® brand to receive updates on oral care and mouthwash relevant topics I agree to being contacted by email by the LISTERINE® brand to receive updates on oral care and mouthwash relevant topics I agree to being contacted by email to participate in anonymous research studies on behalf of the LISTERINE® brand I agree to being contacted by email to participate in anonymous research studies on behalf of the LISTERINE® brand I would like to participate in the Habit Change Challenge TM(personal trial program) and receive product samples from the LISTERINE® brand via post and receive email communication about the challenge I would like to participate in the Habit Change Challenge™ (personal trial program) and receive product samples from the LISTERINE® brand via post and receive email communication about the challenge. Sample Wanted * LISTERINE® Total Care LISTERINE® Total Care Zero Practice Name * Address 1 * Address 2 Town * Postcode * I accept the Terms and Conditions and agree that the information provided will be governed by our Privacy Policy* I accept the Terms and Conditions and agree that the information provided will be governed by our Privacy Policy*. The Promoter reserves all rights to verify all sign ups including but not limited to asking for address and identity details (which must be provided within 14 days). The Promoter may refuse further participation in the programme where there are reasonable grounds to believe there has been a breach of these terms and conditions. Type: Sample Form
