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 = $120 (includes Big Bass)
Tournament #2 = $120 (includes Big Bass)
Tournament #3 = $120 (includes Big Bass)
Tournament #4 = $120 (includes Big Bass)
Tournament #5 = $120 (includes Big Bass)
Tournament #6 = $120 (includes Big Bass)
All Season Deposit = $120 (pay $100 at each tournament)
 Tournament # = $100 Balance Payment (All Season Deposit)

Angler Membership = $40
Little League Membership = $20 (ages 15 and under)
Your Total Is:

Mail This Entry Form To:

Greg Terzia
154 Tanner Rd.
Choudrant, LA 71227

Phone: 318-278-4498

Email
Entry Fee = $120 (includes Big Bass)
Membership Fee = $40 per adult
16 years and older

Little League Entry Fee = FREE
Membership Fee = $20 per youth
15 years and younger

Membership is good for all season events