Your Name:

Your Address:

City: State: Zip Code:

Your e-Mail Address:

Your Phone #:

Your Birthday (needed for USCF & PSCF memberships):

Your Grade (a "C" for college/university student):

Section to enter:

Your USCF ID #: Expiration Date: Rating: ( February 2012 Regular rating)

Byes Needed in Rounds (Players may request ½-Byes in rounds for which they are not available to play. Limited to one round.):

If representing a school, School Name:

and Coach/Captain Name:

If representing a club, Club Name:

and Coach/Captain Name:

Entry Fee:

USCF Membership Fee (required if your USCF membership has expired, Adult $43, Young Adult $30, Youth $25, Scholastic $21):

PSCF Membership Fee (required if your PSCF membership has expired, $5):

Total Fees (Make checks payable to : PSCF):