Online Registration

Must be received by May 9th, 2019

MINE RESCUE, FIRST AID, BENCH AND PRE-SHIFT EXAMINER'S CONTESTS
JUNE 4th, 5th, 6th, 2019 — Cadiz, OH

Company Name:

City:
State:
 

TEAM # 1


Name:

TEAM WILL PROVIDE OWN COMPUTER AND VISIO MAPPING PROGRAM:


REGISTRATION FEE:


FIRST AID TEAM PERSONNEL — REGISTRATION FEE $150 PER TEAM

BENCH TEAM REGISTRATION - REGISTRATION FEE $150 PER CONTESTANT

BG-4    Bio-Pak 240-R

PRE-SHIFT MINE EXAMINER - REGISTRATION FEE $150 PER CONTESTANT

TEAM # 2


Name:

TEAM WILL PROVIDE OWN COMPUTER AND VISIO MAPPING PROGRAM:


REGISTRATION FEE:


FIRST AID TEAM PERSONNEL — REGISTRATION FEE $150 PER TEAM

BENCH TEAM REGISTRATION - REGISTRATION FEE $150 PER CONTESTANT

BG-4    Bio-Pak 240-R

PRE-SHIFT MINE EXAMINER - REGISTRATION FEE $150 PER CONTESTANT

BANQUET($35 each)

Number Attending: (Numbers only)

MAILING ADDRESS FOR CORRESPONDENCE

Name:

Address:

Office Phone:

Cell Phone:

E-Mail: