Wildlands Weekend Bass Tournament  9/21/2019  Entry Fee $50    Please print


Name
                                                 Name                                                  
Address                                               Address                                               
City                                                     City                                                    
State/Zip                                             State/Zip                                            
Phone                                                 Phone                                                
Email __________________________  Email ___________________________
By signing this registration form, I hereby waive and release all other contestants, the host
sponsors, FSCofBC, and tournament officials from all claims for  injury and/or damage
incurred in connection with this event.
Signature Boat Owner                                               Signature Rider
                                             ___                                                                                        
Checks Payable to:  
FSCBerks
Send To:  Eric J Wesner
9135 Old Rt. 22
Bethel, PA  19507
Entry Fee   ($50)               
Double Dip ($10)             (optional)
Lunker       ($10)              (optional)
Total              
Pay-Back 80%  of Entry fees
less expenses    
100% Double Dip & Lunker
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Boat Owner
Rider