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The Southern Flames present  Gerry White PMC Lottery Form

 Name:                                                                                                              

Address:                                                                                                          

                                                                                                                       

Telephone:                                                                                                       

Alternate Telephone (mobile):                                                                           

Email Address:                                                                                                 

 

GERRY WHITE Class Preference (only check one):

 

              I want to attend Class 1 only – Saturday, September 13.

              I want to attend Class 2 only – Sunday, September 14 (I have had the prerequisite basic PMC   instruction)

              I want to attend both classes – Saturday, September 13 and Sunday, September 14

 

                    Do you want to be on the waiting list if your name is not drawn for a class session (circle one)?  yes    no

 

Please print out and complete this form.  Mail the completed form and your check in the amount of $105.00 for one class, or 2 separate checks in the amount of $105.00 for both classes, made payable to “Southern Flames” to: 

Southern Flames

c/o Martha Fuerst

2679 Mercedes Drive NE

Atlanta, Georgia 30345-3974

 

NOTE:  CHECKS AND FORMS MUST BE RECEIVED BY August 2, 2008. 

(Two checks, $105 each, if you want to take both classes.)

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For Southern Flames Administrative Use Only

Received On _________   Check # __________

 

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