Captain’s Entry Form

Make check payable to and mail form to

Oriental Rotary Club Tarpon Tournament, PO Box 205, Oriental, NC 28571

Captain’s Name____________________________________________
Address____________________________________________
City State Zip_________________________ , ______ _________
Telephone: ( _______ ) ________________________
e-mail (optional) ______________________________
Boat Info. (make & length) ___________________________________
Engine Mfg. ________________ Type: _____(I/O, IB, OB)
Boat Name: _________________________________
Hull Color ?_______________ VHF? ___ Head? ___

Entry Fee Schedule

Before 5:00 PM 6/25/04 - $200.00
Before 5:00 PM 7/28/04 - $275.00
After 5:00 PM 7/28/04 - $325.00

Entry Fee Enclosed (Inc. 4 BBQ tickets) ____________
Extra BBQ Tickets ____ @ $10.00 ____________

Bait (50# Spot /Croaker ) _____ @ $75.00 ____________

Championship TWT $150.00 ____________

Sportsman TWT $100.00 ____________

TOTAL ______________

.

I, as Entrant, do hereby RELEASE, DISCHARGE and HOLD HARMLESS, ORIENTAL ROTARY CLUB TARPON TOURNAMENT, its officers, directors, sponsors, and agents, whether individual or corporate, from any claim for damages to my person or property incurred by my participation in the Tournament. This release applies to all members of my crew and all parties fishing from or occupying my boat. By signing the entry form and paying the entry fee, I acknowledge that I have read this release and am bound by same. This release shall also be binding on my heirs, executors, administrator, or assigns.

Signature (required) _________________________________

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