26^th ROBERT H. ELLIOTT MID-AMATEUR CHAMPIONSHIP

SEPTEMBER 24, 25, & 26, 2009

PASSACONAWAY COUNTRY CLUB – LITCHFIELD, NH
&
STONEBRIDGE COUNTRY CLUB – GOFFSTOWN, NH

Enclose entry fee of $110 payable to NHGA

Send payment to:

New Hampshire Golf Association, P.O. Box 486, Wolfeboro, NH 03894

Please print and complete every blank

NAME __________________________________________________________________________

ADDRESS ______________________________________________PHONE___________________

CITY ___________________________________STATE ________ ZIP ______________________

CLUB ____________________________________________________

DATE OF BIRTH ______________________ AGE AS OF SEPTEMBER 24, 2009 ______________

EMAIL ADDRESS __________________________________________

GHIN NUMBER (NOT HANDICAP INDEX) ____________________________

____ I will want a cart

____ I do not want my picture on the web-site

I agree to the championship regulations on the pages of the application. I have read and understand the requirements of eligibility and for acceptance of this entry. I agree this entry is subject to approval or rejection at any time by the New Hampshire Golf Association at its discretion. All contestants must abide by the rules of the host club.

Signature of Applicant _______________________________________ Date ________________

Mid Amateur