Printable Registration Form
L. I. BUGHOUSE Tournament - Friday, Oct. 21, 2011
TO ENTER: Please write ONE check, or use ONE credit card for each Team’s Entry Fee.
Please check Pre-registration Lists upon arrival.
c rec’d by Oct. 14: $17.00 per player ($34.00/Team) c rec’d by Oct. 20 (2pm): $19.00 per player ($38.00/Team)
c rec’d on Fri. Oct. 21 - On-Site (cash only, accepted 5:30 - 6:00pm,) – $22.00 per player ($44.00/Team)
After 6:00pm, you will miss the first round
«CHOOSE A TEAM NAME: _________________________________________________
c If this is a Parent-Child Team, please check this box to qualify for the Parent-Child Trophy.
Board 1: Name___________________________________ Phone _________________ Grade: ____ Rating (or “Unrated”): ______
Board 2: Name____________________________________ Phone _________________ Grade: ____ Rating (or “Unrated”): ______
Address (or “same”)
Make check payable to:
L. I. Chess Nuts Mail to: L. I. Chess Nuts - Bughouse,
or fill in Credit Card info (1 credit card per Team) - mail to the above address or fax to (516) 739-0535:
c Am Ex
Print Name as it appears on Card: _________________________________________________
Account #: _____________________________________ Expir. Date: _______ Total Charged (same as above): $ ________
Signature for Credit Card:
Signature for Credit Card: ______________________________________________________________________________