TO RECEIVE THE $5 PLAYER DISCOUNT YOU MUST HAVE SIX PLAYERS MINIMUM ON THIS FORM.  THEY CAN BE IN DIFFERENT DIVISIONS. TEAM ENTRIES MOST BE SUBMITTED ONLINE BY WEDNESDAY, FEBRUARY 1, 2012.

ACADEMIC SCHOOL TEAM NAME: 

ADVISOR/COACH'S NAME: 

COACH'S E-MAIL: 

COACH'S PHONE: 

TEAM MEMBERS:

In the box that follows please list team members, USCF   ID # (a must to get discount), Expiration date, most current rating, and age group they are playing in.  You can also list them in the 4-6  Open if  they want to compete in that group.

Each player is $30.

TOTAL:

PLEASE INDICATE METHOD OF PAYMENT: Check Credit Card
If you are paying by credit card, please fill out the information below.  If paying by check, mail no later then Tuesday, February 10.  Please make the check out to SUCCESS CHESS SCHOOL and send it to me Alan M. Kirshner, Ph.D., at 66 Indian Hill Place, Fremont, CA 94539.

CREDIT CARD ENTRIES: Visa MasterCard American Express

NAME ON CARD:

CARD NUMBER: 

DATE CARD EXPIRES:

ELECTRONIC SIGNATURE: 

(LATE REG = at site if space is available before 9:30 AM.  Late entrants will not play the first round and will receive a zero point bye for that game.)

*No refunds after Saturday, January 28.  However, if Alan is notified before the tournament starts of an emergency where you cannot attend, an 80% credit of what you paid will be provided for a future Success Chess School/Weibel Chess tournament. Player substitutions can be made as long as they are done by Saturday, February 4 before noon.