Victorian Reining Horse Association
Proudly Presents the
2014 State and Derby Championship Show
Werribee Park National Equestrian Centre
K Road, Werribee
E N T R Y F O R M – Per horse rider combination – Entries close Monday 6th March 2014
Rider:
Owner (if different)
Horse Name:
Mobile Phone Number:
Email Address:
Prize Money Payout To:
Postal Address For Payouts:
Rider NRHA #
Owner NRHA #
NRHA Competition License #
2014 VRHA Member #
Rider RA #
Owner RA #
PLEASE CHOOSE ONE OF THE PRIZE MONEY PAYMENT OPTIONS BELOW: (Tick a box & print clearly)
CHEQUE:
Name:
Address:
P/Code:
ELECTRONIC FUNDS TRANSFER (EFT)
Account Name:
BSB:
Account No:
SHOW FEE
DIVISION #
CLASS
VIDEO FEE
ENTRY
FEE
(Open, Non Pro, and
NON PRO & OPEN
JUDGE
FEE
TOTAL
(compulsory
$5 per run)
DERBY ONLY)
$5
$5
$5
$
$
$
$5
$
$5
$
$5
$
$5
$
$5
$
$5
OPEN PEN
$
$5
$
(will be charged at $40 per horse from Wednesday to Saturday inclusive)
PAID TIMES ($10 per 5 mins)
please circle
$ 40
Number
WEDNESDAY
12:00pm – 4:00pm
Separate
Together
$
WEDNESDAY
6:00pm – 9:00pm
Separate
Together
$
OFFICE FEE per horse
$ 30.00
SHAVINGS supplied by TATURA PINE SHAVINGS – BULKA BAG $88 (inc…GST)
NUMBER:
X $88 =
$
WPNEC FACILITY FEE @ $16 PER HORSE per day (compulsory)
NUMBER:
X $16 =
$
Friday Night Pizza Party (all you can eat)
NUMBER:
X $25 =
($25 adult, $12.50 children 5-12yo, under 5 free)
X $12.50 =
$
$
Saturday Night Derby Dinner Tickets ($25 ADULT, $11 CHILD)
VRHA MEMBERSHIP (refer to VRHA Website for forms if needed)
$
TOTAL $