3rd Annual Golf Registration

Please complete the requested information to register online. . .  If you prefer to register through the mail please 'print' and complete this form before 05/11/2001.  Submit with a check or credit card info to Pgh-AHU, POB 6470, Pittsburgh, PA 15212.

Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip Code
Work Phone
FAX
E-mail
URL

List Your Name & All Members of your Golf Group Below:  $100 individual - $360 per Foursome

For Tee/Green Sponsorship $100 and Type 'TEE/GREEN SPONSOR'

 $ Amount First & Last Name
$100/$90
Player 1
$100/$90
Player 2
$100/$90
Player 3
$100/$90
Player 4
$100
TEE Sponsor (Optional)
CREDIT CARD BILLING

Credit Card

 Select Type
Cardholder Name As it appears on card
Card Number 9999 9999 9999 9999
Expiration Date 99-99
CHECKING ACCOUNT BILLING
Bank Name Your bank name
Account Name Title of the account
Account Number Your Account No.
ABA Route Number 9-digit number

Order date ... :

-- mm-dd-yyyy

By 'clicking' on the SUBMIT button I authorize the Pgh-AHU, or it's agent, to deduct the amount(s) requested on this online registration form from my account.  I further acknowledge I must cancel my reservation(s) by Friday May 11,  2001 in order to avoid charges to my account.  Failure to cancel a reservation prior to this date will cause my account to be charged the full amount of the reservation fee.  PLEASE NOTE: Accounts may be charged prior the Golf Outing on May 14, 2001.
Pgh-AHU Registration Form
Copyright © 2001 Pittsburgh Association of Health Underwriters. All rights reserved.
Revised: September 01, 2004