Last Name:    First Name:    M.I.:

Street: 

City:  State:  Zipcode: 

e-mail address: 

Phone Number:     Date of Birth: 

Highpower Classification:  HM MA EX SS MK None   Long Range Classification:  HM MA EX SS MK None

Full-time Student:  Yes No

Do you have a Palma Rifle:  Yes No

If "Yes" please provide specifics:

Receiver: 

Barrel: 

Sights:    If other than Warner state why: 

Information provided in this form will be kept confidential, and used only the the management of the Under 21/25 Team.