On-line Registration

[This form is used to register on-line; must print out form and send it in with payment.]

Rider 1:
Rider 2:
Address:
City:`
State:               Zip:

Telephone: (Please include Area code)
Email1:
Email2:

Club Affiliation
(if any):
Chapter:

Selection	Choice	Quantity	Price	Total
	Site List & Banquet		@ $35=
	Banquet Only (no ride)		@ $25 =
	Site List Only (no banquet)		@ $10 =
	Attend Banquet (no dinner)		@ $10 =
	Note: At-the-door Banquet		$30
			Grand Total

I/We the undersigned, agree to and will comply with the rules covering this event. I/We
further agree to hold harmless the GWTA, its officers and representatives, or persons
sponsoring this event for loss or injury to property or myself incurred by reason of
participation in this event. I have read and understand the above.


Rider 1 signature		Rider 2 signature

When printing out and sending in, please make checks payable to: GWTA Chapter E,
and mail them to:

Wing Washington
c/o Jerry Weltner
7708 147th Ave NE
Redmond, WA 98052
Wing Washington 2012 Registration Flyer

Send mail to jerry@weltner.net with questions or comments about this web site.
Last modified: 11/10/2011