26th Annual Florida Chapter NCRS Winter Regional Meet January 21-25th 2004 Old Town Vender Registration Name:_____________________________________________ Address:___________________________________________ City:__________________ State:_______ Zip:___________ Business Name:_____________________________________ Phone # ___________ Total Vender Registration $45 $ 45.00 Register Guest $15 $______ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Spaces 15 x 15 Space @35 Ea. # Spaces ______ $ _______ 10 x 20 Space @55 Ea. # Spaces ______ $ _______ 15 x 30 Space @70 Ea. # Spaces ______ $ _______ For Sale Corral $ 30 # Spaces ______ $_______ --------------------------------------------------------------------------------------------- NCRS Memberships National Dues $31 USA/$35 Canadian $_______ Florida Chapter $ 10 $_______ ---------------------------------------------------------------------------------------------- Make Checks Payable Florida Chapter NCRS Total $________ Mail to:Tyler Townsley PO Box 208 Nichols Fl 33863 (Deadline postmark 1/15/03) Phone:863-428-1410 registration Host Hotel: Days Suites Tel 800-327-9126 Hold Harmless agreement: I agree to provide insurance on my vehicles and property against loss, damage and liability and provide proof of insurance to NCRS. I agree to assume all risk of any damage and injury and to indemnify and hold harmless NCRS, its officers,agents,employees and chapter for any acts or omissions which may result in theft,damage or destruction of my property to me or to others or as a consequence of this meet. Signature: ______________________ Date:________ Insurance company_________________________ Policy # ____________________ Event Chairman Ed Augustine 352-394-6547 All tents must be fireproof and have fire extinguisher.