PECONIC BAY FISHING TOURNAMENT
FOR THE THE BENEFIT OF THE LYME DISEASE ASSOCIATION, INC.
JUNE 12, 2010
ANGLER REGISTRATION FORM
NAME: __________________________________________________________________________
MAILING ADDRESS: ________________________________________________________________
CITY/STATE/ZIP: __________________________________________________________________
PHONE: (_____)______________________ FAX: (_____)_______________________________
EMAIL ADDRESS: _______________________________________________________
Please complete the following by placing the names of the individuals who will be on a team.
Please indicate T-Shirt Size for Each Angler in your party. (S-M-L-XL)
SIZE 
NAME: _____________________________ _______ _______ We will need a guide/boat.
NAME: _____________________________ _______ _______ We will bring our own boat.
NAME: _____________________________ _______ _______ We will bring our own boat.
NAME: ______________________________ ________ _______
(Please complete information below.) (Please copy registration form to add additional names.)
NAME OF YOUR BOAT: _______________________________________________________
NAME OF OWNER: __________________________________________________________
NAME OF OWNER: __________________________________________________________
A Captain's Meeting will be held at 7:00 PM on Friday, June 11, 2010, at Strong's Marine in Mattituck. It is strongly recommended that all Captains attend. The rules, along with other issues, will be discussed at this meeting.
The Registration donation is $150.00 per boat, which includes two (2) Anglers, and $50.00 for each addition Angler. The donation for an individual Angler without a boat is $75.00. Junior Division participants (ages 14 and under) donation is $50.00. Each Angler will receive a complimentary T-Shirt, hat & raffle ticket at Registration, and a ticket to the After-Tournament Bar-B-Que at Strong's Marine.
Non-Fishing attendees donation is $25.00 a person, which includes a raffle ticket and a ticket to the After-Tournament Bar-B-Que at Strong's Marina. There will be _________ non-fishing attendees in my party who will attend the Raffle and Bar-B-Que.
Please complete the Registration Form and return with check made payable to the Lyme Disease Association, and mail no later than May 21, 2010 to:
Peconic Bay Fishing Tournament, Inc.
c/o Michael Cirrito
58 Hilton Avenue
c/o Michael Cirrito
58 Hilton Avenue
Hempstead, New York 11550
Cancellation Policy: A $25.00 administrative fee will be charged for any cancellation prior to May 21, 2010. After May 31, 2010, NO REFUNDS will be given due to cancellations or no shows. All refund requests must be submitted in writing by May 31, 2010.
Participants in the First Annual Peconic Bay Fishing Tournament enter at their own risk. Officials, committee members and marina personnel and all persons connected directly or indirectly with this tournament shall be exempt from any liability for loss, damage, negligence, harm or injury suffered by any participant, entrant, sport fisherman, their companions, boat captains and crew members, vessels and equipment, which may occur during the tournament.
Print Name(s) of Applicant(s) Signature(s) of Applicant(s)
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
_________________________________________ ______________________________________
NAME: ___________________________________________
FEES:
_____BOAT(S) @ $150.00 ea. (Includes two (2) Anglers) TOTAL: ___________
_____ANGLER(S) in addition to those included above @ $50.00 ea. TOTAL: ___________
_____ANGLER(S) in addition to those included above @ $50.00 ea. TOTAL: ___________
_____ANGLERS ea. @ $75.00 TOTAL: ___________
_____JUNIOR DIVISION ANGERS ea. @ $50.00 TOTAL: ___________
_____NON-FISHING PARTICIPANTS ea. @ $25.00 TOTAL: __________
_____SORRY, I CANNOT ATTEND THE EVENT, BUT PLEASE, ACCEPT MY CONTRIBUTION
ENCLOSED. ____________
TOTAL ENCLOSED: ____________
Website: www.peconicbayfishing.org
Your support of the First Annual Peconic Bay Fishing Tournament qualifies as a charitable contribution and is deductible for Federal Income Tax purposes and may be deductible for State Income Tax purposes. Check with your tax advisor.
Lyme Disease Association Federal Tax ID # 22-3123551.
Artwork courtesy of jaxsfish.
Tournament administered by Peconic Bay Fishing Tournament, Inc.
