Print this form and mail or fax with payment to address below
PENNSYLVANIA STATE OPEN PHEASANT CHAMPIONSHIP
FILL OUT ONE FORM PER ENTRY / RUN (Reproduce this form for multiple entries)

Division: (check one only)
Single Pointing______ Single Flushing______ Team Pointing______ Team Flushing______
Puppy Pointing______ Puppy Flushing______
(Each dog may run a maximum of two times per division. i.e. two single runs and two team runs)
Preferred Day / Time (check any or all) Sat. AM_____ Sat. PM_____ Sun. AM_____ Sun. PM_____
Run Times will be assigned in order entries are received. We will contact you only if your preferred
time is not available. Post cards will be mailed with exact run times 1 week prior to event.

Entry Fees: $110 Single Divisions ($20 returned to prize money)
$165 Team Divisions ($30 returned to prize money) (Payout to 1^st, 2nd and 3rd in each class)
$65 Puppy Divisions (under 18 months) ($10 returned) Payout to 1^st and 2nd in each class)  $______
                  Option Pool Entry (pays 50% - 30% - 20% in class) $25.00                                $______
                                                                                                        Total for this run.            $______
Team Captain: Name______________________________________________________________
Address_________________________________________________________________________
City_____________________________________________State_____________ Zip____________
Phone (Day)_(____)_____________ (Evening)_(____)______________e-mail__________________
Partner: (team only) Name___________________________________________________________
Address__________________________________________________________________________
City_____________________________________________State_____________ Zip____________
Phone (Day)_(____)_____________ (Evening)_(____)______________e-mail__________________
Dog: Name________________________________________________________
Breed_____________________________________________________________
Birth Date____________________________________(You must provide proof for puppy divisions)
Titles or Accomplishments __________________________________________________________
______________________________________________________________________________

TOTALS FOR ALL ENTRIES (Fill out one only for entire event)

----# of Single Entries: Pointing Breeds _____ Flushing Breeds _____ @$110 per run     $______
                                                                                  Options _____ @$25 per run        $______
----# of Team Entries: Pointing Breeds _____ Flushing Breeds _____ @$165 per run     $______
                                                                                  Options _____ @$25 per run        $______
----# of Puppy Entries: Pointing Breeds _____ Flushing Breeds _____ @$65 per run         $______   
                                                                                   Options _____ @$25 per run           $______     
                                                                                                        Total Entry Fees:      $______

PAYMENT METHOD:   CHECK___ VISA___ MC___ AMEX___ Discover___
Card #___________________________Exp. Date ______Signature______________________
WARRIORS MARK WINGSHOOTING LODGE, 548 Hunt Club Dr., Ginter, PA 16651
(814) 378-8380 Fax: (814) 378-8381 www.warriorsmark.com