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Player's Name:Level:

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(first)(middle)(Last)

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Payment may be made in up to four equal monthly payments. Either by credit card, checking account

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direct withdrawal or by post dated checks. Please fill out the appropriate section below, sign, date and

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return completed form to the AYHA. Note: Registration fee is not included in the Program fee but may be

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processed with first payment.

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PROGRAM FEE

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Total Amount to be Charged / Paid $Number of Payments: 1 2 3 4

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(please circle)

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Amount to be charged per payment$________________

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REGISTRATION FEE

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Please check here if you would like the Registration fee of $150.00 to be made with your first

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payment as per information completed below (registration fee is included as part of the Program fee).

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Please choose one of the following three options for Payment

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Credit Card Information

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Name on Credit Card:____________________________

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Credit Card Number:_____________________________Exp. Date:__________

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Type of Credit Card: Visa Master Card Discover American Express (please circle one)

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OR

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Checking Account Direct Withdrawal

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Bank Name:

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Bank ABA Number:

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Name on Account:

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Checking Account Number:

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OR

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Post Dated Checks

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Check dated August 16, 2008:Check #:Check Amount:

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Check dated September 15, 2008:Check #:Check Amount:

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Check dated October 15, 2008:Check #:________Check Amount:________________

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Check dated November 15, 2008:Check #:Check Amount:

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(Checks must accompany form)

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A 4% processing fee will be added to each c.c. payment.

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Monthly payments/withdrawals will be made on August 16, September 15, October 15 and November 15, 2008.

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Any Non Sufficient Funds returns will be reprocessed with an additional $35.00 NSF fee.

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Authorized Signature:______Date:

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Phone #:

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Address:

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