Registration Form

Name *

Company Name

Address *

City, State, Zip *

Telephone *

Ext:

Email Address *

Teammates

1
2
3

Payment Method *

	Check / Money Order (Make payable to: Midland Information Systems)
	Credit Card (Complete the CC Purchase Authorization Below) If selecting this payment method, please print this form & mail or fax.

Credit Card Purchase Authorization

To pre-pay your registration fees before the Tournament using the below information. You can print this form
and send it to Midland Information Systems, Inc., Attn: Mike Illies, 2130 Platinum Road, Apopka, FL
32703, or you can fax a copy of this form to (407) 571-3105. All fields below are required.

Check if Billing is the same as above

Entry Fee

Golf Tournament Entry Fee, Dinner, 3 Raffle Tickets, Putting Contest and 4 Closets to the Pin Contests
	X $95.00 per person
# of golfers	registration fees	Entry Fee Totals

Extra Raffle Tickets

Prize Drawings
	$2/each or 6 for $10.00
# of Extra Raffle Tickets		100% goes to Charity

50/50 Raffle Tickets

50% goes to the Winner of drawing and 50% to the Charity
	$10/each or 3/$20
# of 50/50 Raffle Tickets

Super Ticket Package A

6 Extra Raffle Tickets and (1) 50/50 Raffle Ticket
	$15/each
# of SuperTicket A

Super Ticket Package B

6 Extra Raffle Tickets and (3) 50/50 Raffle Tickets
	$25/each
# of SuperTicket B

Cardholder's Name *
(as it appears on the card)

Business Name *
(as it appears on the card)

Billing Address *

City, State, Zip *

Credit Card Type *

Credit Card Number *

Expiry Date *

Card Verification # *

Total Sale Amount *


total amount charged

CARDHOLDER SIGNATURE

The undersigned cardholder agrees to pay the Total Sale Amount according to the terms and
conditions of the cardholder's agreement.

Authorized Signature *