5-State Breeders Barrel Futurity Entry Form

13 T H A N N U A L

September 10-12th, 2010
Rapid City, South Dakota

Futurity Nominations due May 1st - Maturity Nominations due June 1st

All substitutions and late payments/nominations MUST be received by August 30, 2010. NO EXCEPTIONS and late fees will be assessed as stated in the rules.

Check one ( ) Futurity ( ) Maturity Check If Eligible ( ) Amateur Division One Horse Per Entry Blank, Please Print

Name of Horse Registration No.

Month & Year Foaled Sex Color

Sire's Name Dam's Name (if dam has run in a previous 5-State futurity or maturity indicate so here)

***Feel Free To Make Additional Copies of This Entry Form***

I (we) hereby make application to enter the above named horse in the 5-STATE BREEDERS BARREL FUTURITY. The Futurity is subject to the rules (CLICK HERE) on the attached sheets, all of which I (we) have read and agree to the provisions contained therein as a part of this Contract. I (we) agree that ALL 5-State Breeders Barrel Futurity decisions are to be FINAL. I (we) hereby release the above 5-State Breeders Barrel Futurity, LI Productions, futurity co-sponsors, and the Central States Fairgrounds from any claim or loss to myself, rider, employee, horses and/or equipment.

OWNER date_______________

RIDER date_______________

Owner's name

Rider's Name

Address

City, State & Zip

Phone:

Signature - Parent if Minor

Indicate to whom 5-State winnings are to be written to

contact email address_______________________

( ) owner ( )rider SSN__________________________________

Please print, fill out and mail entry blank's with attached photocopy (back and front) of registration papers with appropriate fees (See Rules) to: 5-State Breeders Barrel Futurity, Lana Ireland, 22650 151st Ave., Box Elder, SD 57719, 605-431-9480.

OFFICE USE ONLY
Futurity Payments $70 Maturity Payments $50
	Date Paid	Amount	Late Charge	Balance
May
June
July
August
TOTAL