9th Annual Scramble For A Cure Golf Tournament Benefitting the Pulmonary Hypertension Association Registration Form Name ______________________________________________________________________ Company ______________________________________________________________________ Address ______________________________________________________________________ City _______________________________________ State _________ Zip __________ Phone _______________________________________ Fax __________________________ E-mail ______________________________________________________________________ ____ Foursomes at $420 per team ____________ ____ Individual entries at $115 per player ____________ ____ Luncheons only at $35 per person ____________ ____ Balls for the Ball Drop at $20 per ball ____________ Total ____________ Tournament Participants Name Shirt Size ________________________________________________________________ ____________ ________________________________________________________________ ____________ ________________________________________________________________ ____________ ________________________________________________________________ ____________ To Pay By Credit Card: Name (as on card) ____________________________________________________________ Address ____________________________________________________________ Phone ____________________________________________________________ Credit Card No. ____________________________________________________________ Expiration Date ____________________________________________________________ Signature ____________________________________________________________ To Pay By Check: Please make checks payable to: Pulmonary Hypertension Association Mail form and payment to: Scramble For A Cure c/o Jack Nino 2104 Lipari Ct. Las Vegas, NV 89123 702-250-2214 info@scramble4acure.com The Pulmonary Hypertension Association is a nonprofit 501(c)(3) organization. (Tax Id: 65-0880021)