REGISTER YOUNG'S JERSEY DAIRY

print the page and mail check to:

Mike Peirano

2921 Archer Dr

Springfield, Oh 45503

Registration Info

Pre-registration will be open from 4 Dec until Jul 14

WE STOP ORDERED FOR T-SHIRT 26 JUN 06.

First Name: __________________________

Last Name: __________________________

Email Address: _______________________

Address: ________________________

                        ____________________________________

                        ____________________________________

City:       ________________________

State:      ________________________

Zip:        ____________

Country: ____________________

Evening Phone: __________________

Day Phone:         __________________

Year PT Cruiser: __________  Color: ___________________

Registration Fee:              $15.00

# Attending: ____________

Additional Attendees: _________________________________

______________________________________________________________________________

______________________________________________________________________________

T-shirt: S/M/L/XL  $10.00 - 2X  $12.00 - 3X $13.00

T-shirt: S         Number:

              M        Number:

              L         Number:

              XL      Number:

              2X       Number:

              3X       Number:

Registrations Fee:            $15.00

T-shirt:                          +  $

                                   ________________

Total costs:                        $

Phone - 937-399-2479

Cell  -    937-360-1551

Email: peiranom@aol.com