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