0927e Participant, Companion and Volunteer Fees, National Vete

OMB Number:
Respondent Burden: 20 minutes

PARTICIPANT, COMPANION AND
VOLUNTEER FEES
NATIONAL VETERANS TEE TOURNAMENT

PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17,
Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use"
disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient
Databases - VA”. Providing the requested information is voluntary. However, you will not be able to participate in the event without
furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor,
and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this application will average 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
PARTICIPANT'S NAME (Last, First, MI)
COMPANION OR

COMPANION'S NAME

VOLUNTEER INFORMATION

ADDRESS (Street, City, State, Zip Code)

RELATIONSHIP TO PARTICIPANT
WORK TELEPHONE
NUMBER (Include area code)

HOME PHONE NUMBER
(Include area code)

CELL PHONE NUMBER
(Include area code)

IN CASE OF EMERGENCY, CONTACT WORK PHONE NUMBER HOME PHONE NUMBER RELATIONSHIP
(Name, Last, First, MI)
(Include area code)
(Include area code)
COMPANION MEALS: $75 (all meals, Monday evening through Friday morning)
COMPANION LODGING:
NUMBER OF NIGHTS. IF SHARING A
ROOM WITH A PARTICIPANT, TIMES $35
PER NIGHT, PER ROOM

(Number of nights times $35 - TOTAL)

$

$

PARTICIPANT REGISTRATION FEE ($75)

$

EXTRA COST FOR A SINGLE ROOM IS $35 PER NIGHT FOR FOUR NIGHTS
($140 TOTAL). THIS IS ONLY FOR VOLUNTEERS, COMPANION, OR
PARTICIPANTS WHO REQUEST A PRIVATE ROOM.

$

TOTAL AMOUNT:

$

PLEASE RETURN THIS REGISTRATION FORM WITH YOUR CHECK/MONEY ORDER FOR
THE APPROPRIATE FEES (Do not send cash). MAKE CHECKS PAYABLE TO:

MAIL TO:

VA FORM
APR 2010

0927e

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