Date: _____ / _____ / _______ Event:___________________________

Angler Information

Name: ___________________________________ Email: ___________________________________

PH: ________________________________ Address: ________________________________

Co-Angler Information

Name: ___________________________________ Email: ___________________________________

PH: ________________________________ Address: ________________________________

BASIC ENTRY $225.00 OPTION 1 $25.00 BIG FISH $25.00

BOAT MAKE: ___________________________________ YR: _______________ MODEL:___________

ENGINE MAKE: _________________________________ YR:__________________ HP: ____________

TRUCK MAKE: _________________________________ YR:__________________ HP: ____________

Entry fee payout is 80/20%, Option payout is 100% Entry fee after $5 polygraph fee and $25 Championship pot. Pays back 80/20 at a 1 to 6 ratio to 10 places,

Option 1 pays back at 100% and pays 3 places at 50/30/20, Big Fish Option pays back 100% and pays 3 places at 50/30/20.

Returned checks are subject to a $30.00 fee.

DECLARATION I hereby certify that I have read and will comply with all rules and regulations established

by Bass Junkyz and all State and Federal agencies that have jurisdiction over tournament waters to include tow vehicle and boat insurance.

Tournament Director has final authority over any protests, disputes, and the right to refuse service/participation.

With my signature I hereby waive and release from harm the tournament host, director, vendors,

and sponsors from all and any claim negligence, of injury, and/or damages incurred in conjunction with this event.

I have the necessary liability insurance prescribed by the rules to participate in Bass Junkyz events.

I further understand that I am solely responsible for all costs incurred resulting from an incident.

I release any images or video captured by Bass Junkyz, any host, any sponsor, or agency for their use.

SIGNATURES ANGLER: _______________________________ CO-ANGLER: _______________________________

BOAT NUMBER