Name of Club/ Association/ Individual: _____________________________________________

Address: _____________________________________________________________________

City: ______________________________State: _________Zip Code: ___________________

Phone #: ___________________________________Fax #: ____________________________

E-Mail Address: _______________________________________________________________

Please Check: I would like to receive my trial packet by email ( ) or postal mail ( ). If I

choose email, I prefer the info be sent as Word 2003 and Excel 2003 ( ) or as PDF ( ) files.

Name of Trial Committee Chairperson: _____________________________________________

Address (if different than above): __________________________________________________

City: ______________________________State: __________Zip Code: __________________

Phone #: ____________________________________Fax #: ___________________________

E-Mail Address: _______________________________________________________________

Proposed Date(s) For Trial: ___________________________________________________

Name of PLTA Certifier Who is Going to Certify the Trial(s): ___________________________

Trial Locations(s): ______________________________________________________________

One Sanctioning Fee per trial.

Make check or money order payable to PLTA, P.O. Box 388 Garberville, CA 95542