Stratton, Vermont June 26– 30, 2016 This form is valid only until 4

re-
Stratton, Vermont June 26– 30, 2016
This form is valid only until 4/15/2016!
First Name
Last Name
Nick-name ( badge)
Member #
Status (circle one)
_______________________
________________________________
__________________
____________
Member
MOH
Guest
_______________________
________________________________
__________________
____________
Member
MOH
Guest
_______________________
________________________________
__________________
____________
Member
MOH
Guest
Street
__________________________________________________
City
Phone
__________________________________________________
eMail ______________________________________________________________
Please give us your emergency contact info:
_______________________
State
Name: _____________________________________________
_____________
ZIP
_______
Phone: ____________________________
You will receive your confirmation via email - if you have not received a confirmation within 1 week of submitting your form, please call us at 970-667-0460 or email us at
[email protected] If you do not provide an email address we will mail your confirmation to the above address.
I am interested in dual sport riding at STAR: ______ Yes Is this your first STAR? _____ Yes
We will arrive on Fri __, Sat __, Sun__, Mon __, Not sure __
I/We are new MSTA members (Since June 10,2015) _____ Yes
_______ Number of MSTA Members
Includes Wednesday night banquet
(Qty) x $65.00 each
$ ________________
_______ Number of MSTA Members of Household
Includes Wednesday night banquet
(Qty) x $65.00 each
$ ________________
STAR ‘16 Mens Short Sleeve t-shirts:
Sm ____ Med ____ L ____ XL ____ 2X ____ 3X ____ 4X ____
(Total qty) x $15.00 each $ ________________
STAR ‘16 Mens Long Sleeve t-shirts:
Sm ____ Med ____ L ____ XL ____ 2X ____3X ____4X ____
(Total qty) x $20.00 each $ ________________
STAR ‘16 Womens Short Sleeve t-shirts: Sm ____ Med ____ L ____ XL ____ 2X ____ 3X ____ 4X ____ (Total qty) x $15.00 each $ ________________
STAR ‘16 Womens Long Sleeve t-shirts: Sm ____ Med ____ L ____ XL ____ 2X ____3X ____4X ____
(Total qty) x $20.00 each $ ________________
SUBTOTAL
I am a Sustaining ____ Life ____ Member (10% discount)
If applicable, Total from signed MSTA Membership Application form
ENTER DISCOUNT HERE
$ _____________
$ ( _______________ )
$ ________________
_______ Guest registration (Includes banquet)
(Qty) x $40.00 each =
$ ________________
_______ Lunch Ride tickets
(Qty) x $15.00 each =
$ ________________
(Lunch ride is on Tuesday)
_______ Group picture print
(Qty) x $ 8.00 each =
$ ________________
_______ Picture Compact Disks (DVD’s with event pictures)
(Qty) x $15.00 set =
$ ________________
_______ MSTA Ball Cap
(Qty) x $18.00 each =
$ ________________
GRAND TOTAL
(SUBTOTAL - DISCOUNT + ALL OTHER STUFF)
I wish to pay my registration fees by personal check (made out to MSTA) ☐ by Credit Card
If paying by check, return with this form. If payment by Credit Card, authorize below.
$ _____________
☐
HOW TO REGISTER – Fill out this form. If you are not an MSTA member, also fill out the Membership Application or use this
link: http://www.ridemsta.com/
RAFFLE TICKETS – Raffle tickets will be sold on line at:
http://www.planetreg.com/MSTAraffle2016
PAYMENT INFORMATION STAR registration may be paid by personal check (made out to MSTA), or by entering credit card information.
Mail this form to STAR 2015 c/o HEMKO 5560 Stone Church Ct, Loveland, CO 80537.
If paying pre-registration by Credit Card, use the authorization below:
Type of Card
Visa
☐ Master
☐ Discover
970-667-0460
☐ American Express
☐
CC# ________________________________________ Expiration Date _______ (MM/YYYY)
Signature ____________________________________