Last Name: _____________________ |
First Name: ______________
MI: ______ |
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USCF Member:
YES
NO
If Yes, write
USCF ID Here: ____________
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Street Address:
_________________________
_________________________ |
Email: ____________________
Phone: ____________________ |
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City: ____________________, |
VA |
Zip: _________ |
Birth Date: _____________ |
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Section you are entering (circle one):
OPEN
AMATEUR (for ratings under 1800) |
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Optional Bye Requests (choose your byes by circling up to 2 rounds):
Rd 1
Rd 2
Rd 3
Rd 4
Rd 5
Rd 6 |
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Entry Fee
$65 until Aug 28th; |
VCF Membership: $10-Adult;
$5-Junior |
Your Total Payment: _______ |