Northern Division Intent Deposit Form

2018 WR Open Speed Series
January 30 - February 4, 2018
Schweitzer, Sandpoint, ID

Athlete Name: __________________________________________

Mailing Address: ________________________________________


Home Phone: ________________________________Cell Phone: _________________________________

Email Address: ___________________________________________


Non Refundable Deposit $200 (add $10 for credit card fee)

Two Payment Options (Due Jan. 12 by 10 PM):

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: ________________