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 The Southern Flames present  Michael Barley Lottery Form

 Name:                                                                                                              

Address:                                                                                                          

                                                                                                                       

Telephone:                                                                                                       

Alternate Telephone (mobile):                                                                           

Email Address:                                                                                                 

  Michael Barley Class Preference (only check one):

              Only able to attend December 4 & 5, 2004 (Saturday / Sunday)

               Only able to attend December 6 & 7, 2004 (Monday / Tuesday)

               Can attend either session, prefer Sat/Sun – You may be placed in  either class. 

              Can attend either session, prefer Mon/Tues – You may be placed in either class.

 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.  You can either drop this form and your check off at the Saturday, September 11, Southern Flames meeting, or you can mail the completed form and your check in the amount of $350.00 made payable to “Southern Flames” to:

Southern Flames

311 Peachtree Hills Avenue, Box11A

Atlanta, GA  30305

NOTE:  CHECKS AND FORMS MUST BE RECEIVED BY OCTOBER 1, 2004

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For Southern Flames Administrative Use Only

Received On _________   Check # __________

 

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