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| Angler 1 Birthdate Address City State Zip Phone SSN 2006 Membership Fee |
Angler 2 Birthdate Address City State Zip Phone SSN 2006 Membership Fee |
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Lake - Date ----- Total $ Enclosed
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| Mail This Entry Form To: Dewayne Blankenship 13231 Wintergreen Estates Dr. Fenton, MO 63026 Phone: 636-349-7899 |
Entry Fee = $150 per team Membership Fee = $30 per person Membership is good for all 2006 season events |