Official Media Bass LA North Individuals Entry Form (Enter with Credit Card)
Angler

Birthdate    
Address
City
State Zip
Phone
SSN
Email
Little League
Ages 15 and under (must be a member)
 Birthdate    
Address
City
State Zip
Phone
School
Email
Select All That Apply:
 Tournament #1 = $110 (includes Big Bass)
Tournament #2 = $110 (includes Big Bass)
Tournament #3 = $110 (includes Big Bass)
Tournament #4 = $110 (includes Big Bass)
Tournament #5 = $110 (includes Big Bass)
Tournament #6 = $110 (includes Big Bass)
Angler Membership = $35
Little League Membership = $35 (ages 15 and under)
Your Total Is:
Mail This Entry Form To:
Daniel Carter
P.O. Box 581
Stephens, AR 71764

Phone: 870-786-5091
Cell: 870-914-0796

Email

Entry Fee = $110 (includes Big Bass)
Little League Entry = FREE (membership required)
Membership Fee = $35 per person
Membership is good for all 2012 season events