Northern Division Registration & Invoice Form
2007 WR Utah
Tech Series
January 9-12, 2007
Park City and Snowbird, UT
Name: __________________________________________
Address: ________________________________________
________________________________________________
Phone: __________________________________________
Email: ___________________________________________
Travel:
| Fly_______ Drive_______ (check one) |
|||
|
To/From: |
With ________________ |
||
| Arrive date:________ | Arrive time:________ | Flight:________________ | Airline:_______________________ |
| Depart date:_______ | Depart time:_______ | Flight:________________ | Airline:_______________________ |
|
Expense |
Per athlete cost |
| Coaches | $100.00 |
|
Administration Fee |
20.00 |
|
Wax |
15.00 |
| Lifts | 128.00 |
|
Entry fee |
140.00 |
| Coaches' Transportation | 115.00 |
|
Lodging |
$??? |
|
Total without lodging |
$518.00 |
Amount $ Check NO. _______________________
Mail to: Jenn Stielow, Northern Division/USSA
574 Bighorn Circle # BRR; Silverthorne,
CO. 80498
Credit Card Option(**):
Name on Card: _________________________________________
Billing Address: _________________________________________
______________________________________________________
_______________________________________________________
Card Number :____________________________________________
Expiration Date: _____________ Security Code (3digits): __________
**We take Visa, Mastercard, American Express
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.
Signature: __________________________ Date: ________________
**Please note this is an estimated cost amount. You will be sent a credit/debit invoice after the races. Credits will be applied to the next race and payments must be submitted upon receipt in order to continue to travel with Northern Division during the season. If there is a credit at the end of the season a check will appear in your mail per your request.