Check the TLA or web site for the address to send this to:

Name: __________________________________________

Address: ________________________________________

City, State, Zip: __________________________________

Home Phone: ____________________________________

E-mail: _________________________________________

USCF #: _________________________________________

USCF Expiration Date: _____________________________

USCF Rating: _____________________________________

School: _________________________________________

Grade: _________   Coach: _________________________

Section: _________________________________________

Amount Enclosed: _________________________________

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