NAME: ___________________________________ , _________________________________
last
first
PLEASE CIRCLE
ONE: Mr. Ms. Mrs. Dr. Prof. Clergy: ___________________
PROFESSION OR OCCUPATION: ________________________________
STUDENT: Yes / No
FIRM
or SCHOOL: _____________________________________________________________
YOUR ADDRESS: ________________________________________________________________
CITY:
________________________________________ STATE: _________ ZIP: _____________
COUNTRY (if not U.S.A.): _____________________________
________________________
Province
TELEPHONE: (
) ________________
- ___________________
EMAIL
ADDRESS: ______________________________________________________________
EMAIL ADDRESS: _______________________________________________________________
Please repeat in capital letters
TEAM MEMBER: name __________________________________________________________
TEAM MEMBER: name __________________________________________________________
TEAM MEMBER: name __________________________________________________________
SIGN: I have read the competition
rules and agree to abide by them.
_______________________ _____________________________________________
date
signature of individual or team leader
