Contact INFO
Mr Ms Mrs Miss

Name:
Age:
SS#: 
Mailing Address

City

State/Province : 
ZIP Code/Postal Code
PARTNERS NAME (TEEN AND CHILDREN, ONLY)

Email Address

No Change in Entry Fees!  Register Before July 1 and avoid a late fee.
I will register as:

Level	Before July 1  per event	On/After July 1  per event
Adult	$30.00	$40.00
Teens (13-19)	$15.00	$20.00
Childrens (under 13)	$10.00	$15.00

I will play in: Singles Doubles Both

Order your sweepstakes ticket @ $100.00 each.  Winner to receive $15,000 cash.  Please enclose your $100.00 with your registration fees
Yes, I would like  (enter qty) sweekpstakes tickets and am enclosing $100.00 for each.
 

Print this page, attach entry fee(s) and mail to:
World Championship Domino Tournament®
Andalusia Rotary Club
PO Box 276
Andalusia, AL 36420