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2007 Membership and Team Tournament Entry Form - Northern Region
Registration is permitted the morning of an event, however a $10.00 late fee is charged at the Lake.

Today’s Date:___/___/___ Region:__Northern___________ Lake:_____________ Event Date:___/___/___

Boat:______________ HP:_________ Motor:_______________ Troll Motor:______________ Electronics:___________

Boater: Non Boater:
Name:______________________________________________ Name:____________________________________________

Address:____________________________________________ Address:___________________________________________

City, St, Zip_________________________________________ City, St, Zip:______________________________________

Phone(___)____________________SSN:__________________ Phone(___)__________________SSN:__________________

Email_______________________________________________ Email____________________________________________

Membership: ( ) Individual $40 ( ) ___________________________________________________ $___________

Entry Fee: Regular Teams ($130)______________________________________________________ $___________

Entry Fee: Seniors ($70)_____________________________________________________________ $___________

Big Fish: ($20)_____________________________________________________________________ $___________

$10 Option________________________________________________________________________ $___________

$20 Option________________________________________________________________________ $___________

$30 Option________________________________________________________________________ $___________

$40 Option _______________________________________________________________________ $ ___________

$50 Option - Top 3_________________________________________________________________ $ ___________

$5 Insurance Fee: madatory for each team________________________________________________ $___________

Late Fee: ($10)_____________________________________________________________________ $___________

Total Due $___________

Make Checks Payable to 100% BASS – P.O. Box 4112 San Leandro, Ca. 94579 - (530)-613-6586
I have completed this application and have submitted the total fees needed for participation. In consideration for the privilege of participating in this tournament, I hereby release all tournament officials and sponsoring organizations from all claims of injury and /or damages incurred in connection with this event. I understand that I may be subject to a polygraph exam and waive all legal rights to challenge the results of said exam. 100% BASS reserves the right to refuse entry to anyone attempting to enter this event.

Please sign below for release of liability and polygraph waiver

Boater:__________________________ Date:_/_/_ Non Boater:__________________________ Date:_/_/_

Boater:____________________________ Date:___/___/___ Non Boater:____________________________ Date:___/___/___

Boater:__________________________ Date:_/_/_ Non Boater:__________________________ Date:_/_/_