NAME: _____________________________ TITLE: ________________________________

WORK ADDRESS: __________________________________________________________

HOME ADDRESS: __________________________________________________________

PHONE NUMBERS: (Work)____________________ (Home) _________________________

(Fax)_____________________ (Email) __________________________

NUMBER OF ENTRIES (Up to 5):

BRIEF DESCRIPTION AND DATES OF ENTRIES:
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_____ Enclosed is my $25.00 entry fee

I, the undersigned, attest that all work submitted is my own.

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Signature of Entrant Date