Date ______________

Name  _______________________________

Address ______________________________

City ____________________       State _______  Zip __________

Phone (_____) ______-______                 Cell (_____) _______-_______

E-mail ___________________
                                                                        OSRPA member dues~~~~~~~~~~~        $  10.00

Band # ___________________  Letter _______  Color __________________

                                                                        Perch/Entry Fee dues~~~~~~~~~~            $ 100.00

                                                                   Optional Average Speed ~~~~~~~~~~~               $25.00

                                                                                          Buy Back  ~~~~~~~~~~~             $15.00      

                                                                      Total Enclosed ~~~~~~~~~~~~~~~~         $_______

** Please Check Waive signature on your Express Shipping Label. Postman will deliver to house and put inside back door **

Make Checks Payable To:       Medford Racing Pigeon Club

Ship Birds To:                         Gary Gunderson
                                               11575 Duggan Road
                                               Central Point OR 97502
                                               (541) 840-3330  

**Note: Buy Back and Average speed fees are refundable if bird does not go to race.