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PACK LLAMA TRIAL ASSOCIATION, INC. |
(Please Print)
NAME OF CLUB/ ASSOCIATION/ INDIVIDUAL_____________________________________________
ADDRESS: _____________________________________________________________________________
CITY: STATE: ZIP
CODE:
PHONE #: FAX
#: E-MAIL:
I
would like to receive my trial packet by ð email or ð postal mail. If I choose email, I prefer the files be sent
in ð Word 2003 and Excel 2003 or ð PDF format.
NAME OF PLTA CERTIFIER WHO IS GOING TO CERTIFY THE TRIAL: ______________________________
NAME
OF PLTA COMMITTEE CHAIRPERSON: _____________________________________________
ADDRESS: _____________________________________________________________________________
CITY: STATE: ZIP
CODE:
PHONE #: FAX
#: E-MAIL:
PROPOSED
DATE(S) FOR TRIAL(S):
LEVELS
TO BE OFFERED: ( ) BASIC ( ) ADVANCED ( ) MASTER
TRIAL
LOCATION(S)
One
Sanctioning Fee per trial.
( ) FUNDS ENCLOSED IN THE AMOUNT OF $10.00 FOR BASIC ONLY TRIAL
( ) FUNDS ENCLOSED IN THE AMOUNT OF $15.00 FOR BASIC DOUBLE TRIAL
( ) FUNDS ENCLOSED IN THE
AMOUNT OF $20.00 FOR ALL LEVEL TRIAL
( ) FUNDS ENCLOSED IN THE AMOUNTOF $25.00 FOR ALL LEVEL DOUBLE TRIAL
Make
check or money order payable to: PLTA Mail to: PLTA,
NOTE: Proof of Liability Insurance for the trial event MUST BE sent to the PLTA prior to the trial being held.
PLTA SANCTIONING CERTIFICATE
DATE RECEIVED: SANCTION DATE:
This
Certificate is NOT transferable to another club or organization.