COPY, FILL IN AND SEND TO:
Box 'K'
Drifton, Pa. 18221
FAX (570) 453-3855
| Team Name | Team Manager | ||||||||||||||||||
| Address | City | ST. | Zip | Phone (_______) |
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| Tournament Name | Tournament Date | Location | Class | ||||||||||||||||
| Name of insurance Provider | Policy Number | Expiration Date | |||||||||||||||||
|
Fees $______ |
Is your team registered? Please check as applicable |
A.S.A. | N.A.S.F. | OTHER | (If OTHER) Please specify | ||||||||||||||
|
Yes |
No |
Yes |
No |
Yes |
No |
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| Comments | |||||||||||||||||||
| Signature | Date |
CONTACTS:
E-MAIL Nasf@nasf.net Phone (570) 454-1952 * FAX (570) 453-3855 * FAX (570) 455-2605 * CELL-(570) 233-1936