:: Moonlight Run Entry Submission PREVIEW ::

Name :

[r_fname] [r_lname]

 

Address :

[r_address], [r_city], [r_prov], [r_postal]

 

Contact eMail :

[re_email]

 

Phone No.:

[r_phone]

 

Race Distance/Category:

[r_distance][r_gender][r_category]

 

Shirt Size:

[r_shirtsize]

 

Refreshment Ticket:

[r_refreshment]

 

Entry Fee:

$[rd_entryfee]

 

Extra Pizza:

[d_extrapizza]x$2.00=$[]

 

Extra Liquor:

[d_extrabeer]x$2.50=$[]

 

Total Entry: 

 $[]

 

Occupation/School:

[occupation]

Previous Runs:

[previous]

Age:

[age]

Birthday:

[birthday]

Goal:

[goal]

Special Day:

[special]

Fastest:

[time], [fastdistance]

Total Amount:

$[]
this amount will be charged to [r_cardholder]
CC# [r_visa1] [r_visa2] [r_visa3] [r_visa4] Expiry [r_expirymonth]/[r_expiryyear]

 

 

Please check entered data and if everything is OK press "Submit" button,
 if not please push the "back" button of your web browser and edit incorrect fields.

We will confirm your RACE ENTRY within 24 hrs by email
"SORRY" NO REFUNDS