Name: Age:

Address (Include Apt #):

City: State: Zip:

Phone Number: Social Security Number:

Email Address:

Have you ever been a member of the PBA ? Yes No * If yes, date joined?

Are you a Member of ANY other Tournament Clubs or Organizations? Yes No
*Mid-State Masters *Michigan Majors *Other Specify

All 2011-2012 Current Season Averages of 21 games or more:
*MUST LIST ALL AVERAGES AND PROVIDE CURRENT LEAGUE AVERAGE SHEETS FOR VERIFICATION

All 2010-2011 USBC Year Book Averages of 21 games or more:

*SPORT LEAGUE averages or PBA EXPERIENCE league averages cannot be used for division qualification.

*Have you ever been RE-RATED for any tournament event? Yes No
*Have you had any Tournament winnings over $600 in the previous 12 months? Yes No
*If yes, What tournaments and date? __________________________________________________________________________________

Bowling Association Membership:

USBC Sanction #: Is USBC Sanction Current? YES NO