FIRE & POLICE BENEFIT Mx 330-733-6896 200 ENTRY FORM www.firepolicebenefitmx.com All Proceeds Benefit the MAKE A WISH and CHMC of AKRON'S BURN UNIT

NAME__________________________AGE __ MAKE OF BIKE___________

ADDRESS ______________________________ # ON BIKE_____________

CITY _______________________STATE _____ ZIP ___________

PHONE# ___________WORK # ____________ DEPARTMENT ___________

EMAIL _____________________________________
FIRST CLASS $30.00 EACH DAY, EACH ADDITIONAL CLASS $25.00 EACH DAY
FRIDAY JUNE 19	SATURDAY JUNE 20
EXPERT	EXPERT
___ 125	___ 125
___ 250	___ 250
___ OPEN	___ OPEN
INTERMEDIATE	INTERMEDIATE
___ 125	___ 125
___ 250	___ 250
___ OPEN	___ OPEN
NOVICE	NOVICE
___ 125	___ 125		PRE-ENTER BY JUNE 4th AND GET AN EVENT T-SHIRT!
___ 250	___ 250		PRE-ENTER BY JUNE 4th AND GET AN EVENT T-SHIRT!
___ OPEN	___ OPEN
AGE CLASSES	AGE CLASSES
___ +30	___ +30
___ +30 NOVICE	___ +30 NOVICE
___ +40	___ +40
___ +50	___ +50
___ OPEN QUAD	___ OPEN QUAD
___ 2 - STROKE QUAD	___ 2 - STROKE QUAD
___ 4 - STROKE QUAD	___ 4 - STROKE QUAD		SEND ENTRY AND FUNDS TO:
___ UTILITY QUAD	___ UTILITY QUAD		FIRE & POLICE BENEFIT MX
___ FIRST/BEGINNER BIKE	___ FIRST/BEGINNER BIKE		2155 FOREST OAK
___ WOMEN	___ WOMEN		AKRON, OH 44312
___ BOMBER (1990 & older bike)	___ BOMBER (1990 & older bike)
___ CLYDESDALE (+200lbs)	___ CLYDESDALE (+200lbs)
___ 50CC ADULT	___ 50CC ADULT
___ EXTRA BIKE	___ EXTRA BIKE
KIDS CLASSES	KIDS CLASSES
___ 50CC	___ 50CC
___ 60CC	___ 60CC
___ 80CC	___ 80CC
___ 125CC SCHOOLBOY	___ 125CC SCHOOLBOY
___MINI 4 STROKE	___MINI 4 STROKE
___ 125CC SCHOOLBOY	___ 125CC SCHOOLBOY
___ MINI QUAD	___ MINI QUAD
*TOTAL FIRST DAY $ _______ TOTAL SECOND DAY $___________ TOTAL BOTH DAYS $____________*