CONVOY REGISTRATION FORM
12th Annual Make-A-Wish® Truck Convoy
September 10, 2011
Leightys Flea Market
Newry, PA
Activities 9:00 am to 5:00 pm - Convoy begins at 1:30 p.m.
Same day registration opens at 7:00 am
Registration Fee $60.00
Waived if you raise $250 or greater in pledges this year
DRIVER
           
Name:
Address:
Phone:
E-Mail: T-shirt Size:
Are you able to take riders?   If yes, how many?            
Type of Truck: Trailer __ yes  __ no    Size _____
COMPANY
Name:
Address:
Phone:
Checks should be made payable to "Make-A-Wish Convoy"
Please return completed form along with total registration fees to:
Diana Mazzaferro
P.O. Box 112
New Baltimore, PA  15553
A copy of the official registration and financial information may be obtained from the Pennsylvania Department of State by
calling toll-free, within Pennsylvania, 1-800-732-0999.  Registration does not imply endorsement