Athlete Name: __________________________________________
Mailing Address: ________________________________________
________________________________________________
Home Phone: ________________________________Cell Phone: _________________________________
Email Address: ___________________________________________
Travel:
| Fly_______ Drive_______ (check one) | |||
|
To/From: |
With ________________ | ||
| Arrive date:________ | Arrive time:________ | Flight:________________ | Airline:_______________________ |
| Depart date:_______ | Depart time:_______ | Flight:________________ | Airline:_______________________ |
|
Expense |
Per athlete estimate |
|
Coaches & Coaches' Transportation |
$192 |
|
Administration Fee |
20 |
|
Wax |
20 |
|
Lodging |
128 |
|
Lifts |
140 |
|
Entry Fee |
152 |
|
Total Amount |
$652 |
Note: This is an estimated cost amount. Adjustments will be made to your Northern Division account as soon as possible upon return of all receipts and trip expenses. Credits will be applied to your Northern account. Should additional payment be necessary, this amount must be submitted upon invoice receipt in order to continue to travel with Northern Division during the season. If a credit remains at the end of the season, a check will be mailed to you at your request. Feel free to call 406-871-7429 should you have any questions.
Amount $ Check #: _______________________ (We also accept Visa, MasterCard, and American Express. See below.)
Mail to: Sherri Hale, Northern Division USSA, P.O. Box 217, Whitefish, MT 59937
Credit Card Option:
Name on Card: _________________________________________
Billing Address: _________________________________________
______________________________________________________
_______________________________________________________
Card Number :____________________________________________
Expiration Date: _____________ Security Code (3digits): __________
With my signature I agree to pay for the above charged amount of _______ using my credit card that I have provided to Northern Division above. This includes the 4% surcharge to cover bank processing expenses. I understand that this is an estimated trip cost and adjustments will be made after all receipts are in. Credits will be mailed out at the end of the season as requested.
Signature: __________________________ Date: ________________