UNG'S JERSEY DAIR

print the page ad mail check to:

MIKE PEIRANO

  2921 ARCHER DR 

SPRINGFIELD, OH  45503

Registration Info

Pre-Registration now to 30 Sept 2008

Pre-Registrations fee: $15.00. Goody Bags, one T-shirt

and dash plaque.

After 30 Sep 2008 fee: $20.00

First Name: ________________________________

Last Name:  ________________________________

Email Address: _____________________________

Address: __________________________________

               __________________________________

City: ______________________ State: __________

Zip: ______________________ Country: ________

Evening Phone: _____________________________

Day Phone:       _____________________________

Year PT Cruiser: ____________  Color: _______________________

Attending: _______________________________________________

Your Club: ______________________________________________

Your size T-Shirt:                                                _________________

FEE:                                                                     _________________

 

ADDITION Joe's US-40 Grille SHIRT

S     $12.00                                                           _________________   

                             

M    $12.00                                                          _________________

L     $12.00                                                           _________________

XL  $12.00                                                           _________________

2X  $14.00                                                            _________________

3X  $16.00                                                            _________________

4X  $18.00                                                            _________________    

                                      

TOTAL COSTS:                                                    _________________