September 18-19 at Lake Palestine, Texas
Official Media Bass Couples Championship Entry Form (Enter With Credit Card)
Her

Birthdate    
Address
City
State Zip
Phone
SSN
Email
Him

Birthdate    
Address
City
State Zip
Phone
SSN
Email
Tournament Options
Quantity

Cost
Team Championship Package - $200 per team
(includes Entry Fee, Two Dinners, and T-Shirts)
-

$

Team Championship Entry Fee - $170 per team
(includes Big Bass each day)

 $
Championship Dinners - $10 per person
 $
Championship T-Shirts - $10 per person
-
$
 
Total -

$
Make Checks Payable to: Media Bass
Mail This Entry Form To:
Media Bass
3309 Riverview
Mesquite, TX 75181

Phone: 972-222-2207
Email

 Team Championship Fees
 Championship Package = $200
(includes entry, two dinners, and two T-Shirts)
Entry = $170 (includes daily Big Bass)
Dinner = $10 per person
T-Shirts = $10 per person

Official Media Bass Championship Entry Form (Enter With Credit Card)

MediaBass.com - 3309 Riverview - Mesquite, Texas 75181
(972)222-2207