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The Southern Flames presents
Michael Barley
Lottery/Registration Form
Name:
Address:
Telephone:
Alternate Telephone (mobile):
Email Address:
Class Preference (only check one):
Only able to attend Thurs/Fri March 17-18, 2011
Only able to attend Sat/Sun March 19-20, 2011
Can attend either session, prefer Thursday/Friday -You may be placed in either class.
Can attend either session, prefer Saturday/Sunday – 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. Mail the completed form and your check in the amount of $400.00 ($425 for non-members) made payable to “Southern Flames” to:
Martha Fuerst
2679 Mercedes Drive NE
Atlanta, Georgia 30345-3974
NOTE: IF CHECKS AND FORMS ARE BEING MAILED THEY MUST BE RECEIVED BY January 21, 2011
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For Southern Flames Administrative Use Only Please do not fill in below
Received On _________ Check # __________
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