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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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