Passenger’s Name____________________________________________

___________________________________________________________

Address_____________________________________________________ 

City____________________________ State______________

Zip Code____________________ 

Telephone Number_______________________ 

Cell-phone Number_______________________

Email Address__________________________________________________

Pre-Registration 

open until June 20, 2009

_____X $20.00 Driver/ Rider, _____X $15.00 passenger

_____X $7.00 Children under 16 

$________ Total             

Registration after June 20th

_____X $25 per Adult , ______X $10.00 Children  under 16 

$____________ Total  

T-Shirt Size

Adult     ___S   ___M   ___L  ___ XL   ___2XL   ___3XL

Childs  ___S   ___M  ___ L   ___XL 

Check or Money Orders

Make Payable to:

 National Veterans Memorial

Mail Payment to: 

National Veterans Memorial 

8837 State Rd 57

Elberfeld, IN  47613

Phone 812-795-2230 or 795-2237

Note there will  be a $1.50 service fee 

add for Credit Card processing 

Credit Card Payment

Payment Type:  

Cardholder Name ______________________________

Zip Code _______ Signature ____________________________

Credit Card Number:________________________ 

Expiration Date: _____/____

CVV:___________ 3 digit numbers on the back right on the right