Atlantic Volunteer Fire & Rescue Company, Inc.

ROCKFISH DERBY

DERBY REGISTRATION

Entry Fees:

Individual: $25 per angler, $15 per youth(12 and under)

Entries received by November 19^th will be entered into a special drawing.

(includes dinner at the Anglers meeting Friday, December 2^nd at 6:30pm)

Angler: __________________________________

City:____________State:__________Zip:________

Contact Phone Number: _______________________

Email Address:_____________________________

Angler: __________________________________

City:____________State:__________Zip:________

Contact Phone Number: _______________________

Email Address: ____________________________

Angler: __________________________________

City:____________State:__________Zip:________

Contact Phone Number: _______________________

Email Address: _____________________________

Angler: __________________________________

City:____________State:__________Zip:________

Contact Phone Number: _______________________

Email Address: ____________________________

Angler: __________________________________

City:____________State:__________Zip:________

Contact Phone Number: _______________________

Email Address: ____________________________

Total Entries: ____ @ $25 each = _______

Youth Entries:____ @ $15 each = _______

Extra Dinner Guests______ @ $8 each =______ TOTAL REMITTED: ____________

Please make checks payable to:

Atlantic Volunteer Fire & Rescue Co., Inc.

Registration forms are to be mailed to

AVFR&C Rockfish Derby

C/O Bob Sloan

Post Office Box 388

Atlantic, Virginia 23303

Registration confirmation will be emailed to you.

For Derby Committee Use Only:

Committee member documenting please initial

the action taken…..

Date Registration Received: _____________

Names of Dinner Guests