2006 State Congress Registration Form

Club or Individual registration Club Individual   

Club or Individual:     Club#:

Address:City:Zip

Phone#:Fax#:Email

Contact:Phone#:Email:

Congress Registration Fee $75.00  
Register four or more from the same clubs and pay the club fee of $300.00 for everyone.

Add On Activities & Testing:
The following courses will be offered. You must register with the National Office.
USAG Safety Courses - Sunday, July 23, 2006    2:00 pm - 6:00 pm

Name:     Name:

Name:     Name:

Name:     Name:

Name:     Name:

Name:     Name:

Name:     Name:

Name:     Name:

Name:     Name:

Person Submitting Form:     Amount Due:

Click on the submit button below to send form

Make checks payable to:  IL WPC

Mail Payment to:
Illinois State Congress
Kris Eisenmann
231 Lehigh Lane
Bloomingdale, IL 60108

If you questions please email Kris Eisenmann: emann4@sbcglobal.net