Northern Division Registration & Invoice Form

Western Region U16 Championships
March 19-22, 2015
Mt. Bachelor, Oregon

Athlete Name: __________________________________________

Mailing Address: ________________________________________


Home Phone: ________________________________Cell Phone: _________________________________

Email Address: ___________________________________________



Per athlete estimate

Coaches & Coaches' Transportation


Administration Fee








Entry Fee, Banquet




Total Amount if Paid by Check


Total Amount if Paid by Credit Card


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.

Check Option:

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 5% 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: ________________

Payment Network Option:

The direct payment option is done though our Quickbooks/Intuit Payment Network.  Intuit safely handles financial data and transactions for millions of customers.  Payment Network adheres to rigorous online banking industry protection standard and works hard to protect your information.  Please note that if you use this method and select a Credit Card (as opposed the Bank Account) option, you must add 5% to cover our credit card processing fees.  The 5% is calculated for you in the Athlete Estimate table above.