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 ____________________________________
© Copyright 2018 AnyForm
