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                                  

 

                                                     Enclosed: $ ________

 

«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”): ______

 

    Address ________________________________________________  Town ______________________  State _____  Zip  _______

 

Board 2:  Name____________________________________ Phone  _________________ Grade: ____  Rating (or “Unrated”): ______             

 

    Address (or “same”) ______________________________________  Town ______________________  State _____  Zip  _______

 

Make check payable to:  L. I. Chess Nuts     Mail to: L. I. Chess Nuts - Bughouse,  P.O. Box 1515,  Mineola, NY 11501

 

     or fill in  Credit Card info (1 credit card per Team) - mail to the above address or fax to (516) 739-0535:    

c Mastercard       c Visa      c Discover       c Am Ex

 

     Print Name as it appears on Card:  _________________________________________________

 

     Account #:  _____________________________________  Expir. Date:  _______ Total Charged (same as above): $ ________

Signature for Credit Card:  ______________________________________________________________________________