Northern Division Registration & Invoice Form

Northern Division
Western Region U21/U19 Junior Championships 2017
March 9 - 14, 2017
Schweitzer

Athlete Name: __________________________________________

Mailing Address: ________________________________________

________________________________________________

Home Phone: ________________________________Cell Phone: _________________________________

Email Address: ___________________________________________

Travel:

Expense

Per athlete estimate

Coaches & Coaches' Transportation

$269

Administration Fee

20

Coat

115

Wax (6 days and Speed)

50

Lodging

230

Lifts

216

Entry Fee and Souvenir

292

Total Amount if Paid by Check

$1192

Total Amount if Paid by Credit Card

$1251.60

Note:  This is an estimated cost amount.  Adjustments will be made to your Northern Division account as soon as possible upon return of all receipts and trip expenses.  Credits will be applied to your Northern account.  Should additional payment be necessary, this amount must be submitted upon invoice receipt in order to continue to travel with Northern Division during the season.  If a credit remains at the end of the season, a check will be mailed to you at your request.  Feel free to call 406-871-7429 should you have any questions.


Online Payment Option:

Sherri will send you an invoice to use your Bank Account and pay online.  If you are going to pay online with a credit card, you need to let her know and she will RE-INVOICE YOU, adding an additional 5% for credit card processing.  If you have credits from past races, you also need to let her know so that she can re-invoice you.


Check Option:

Amount  $                       Check #: ______________________ (We also accept Visa, MasterCard, and American Express.  See below.)

Mail to:  Sherri Hale, Northern Division USSA, P.O. Box 217, Whitefish, MT 59937


Credit Card Option:

Name on Card: _________________________________________

Billing Address: _________________________________________

______________________________________________________

_______________________________________________________

Card Number :____________________________________________

Expiration Date: _____________ Security Code (3digits): __________

With my signature I agree to pay for the above charged amount of _______ using my credit card that I have provided to Northern Division above.  This includes the 5% surcharge to cover bank processing expenses.  I understand that this is an estimated trip cost and adjustments will be made after all receipts are in.  Credits will be mailed out at the end of the season as requested.

Signature: __________________________ Date: ________________