Pilot Entry Form

You may submit your entry in any of the following ways:

Use the online form below. This form will be submitted via email directly to the coordinator.
Download, print and mail in the form located here.

You may submit payment for your entries via regular mail or Credit Card as follows:

Regular Mail - Please mail to:
Rotary Poker Run
3500 S. Kanner Hwy, Lot 117
Stuart, FL 34994
Credit Card - Pending

Please also submit a photograph of you and your aircraft and any entrants who will be flying with you to Tony DeLorenzo for inclusion in our online photo album.

Pilot/Entrant Information	* indicates required entry
*First Name
MI
*Last Name
*Phone Number
Fax Number
e-mail
Address

City
State
Zip
*Aircraft Id #(NONE if not a pilot)
Aircraft Type
Number of Seats (0 if not a pilot)
# Seats Available (blank if not a pilot)
Smoker?
Entrant Fees
Pilot/Entrant Fee $100
# Passengers Entering Contest
Passenger Entrant Fees @$100 each
Total # people entering
Total Fees
Payment Method
Check	(submit via regular mail)
Credit Card	Pending
Passenger Information

Passenger #	First Name	MI	Last Name	Weight	Smoke?
1
2
3
4
5