T.E.P.R.A

FULL NAME

NICKNAME*

WHAT OPTION DID YOU CHOOSE

BASIC MEMBERSHIP
NON-CONTESTANT PERMIT
1 RODEO PERMIT
YOUTH PERMIT
ADULT PERMIT

AGE

DOB

SS # (MANDATORY FOR PERMITS)

ADDRESS, CITY, STATE, ZIP

IS ALL INFORMATION TRUE & CORRECT TO THE BEST OF YOUR KNOWLEGE?

YES
NO

ELECTRONIC SIGNATURE

PARENTS SIGNATURE IF UNDER THE LEGAL AGE 18.

WHO SENT YA