Membership Form - Trivia night

Date: Apri 22, 2020

Location: Ironhand Wine Bar

1025 Northside Blvd.

South Bend, IN

Time: 7:00 -9:00 PM

Please choose whether you are playing as a single player or forming a team.

Amount:

Single player

$ 5.00

Team of two players

$ 10.00

Team of four players

$ 20.00

Team of six players

$ 30.00

Team of eight players

$ 40.00

Team information

If you are forming a team, please use the comments section below to list your players.

88.1 WVPE appreciates your comments:

Are you a current member of WVPE?:

Participant Information

Title:

First name:

Middle name:

Last name:

Country:

Address lines:

City:

State:

ZIP:

Phone:

Email:

Payment Information

Name on card:

Credit Card Number:

Card Type:

Card Expiration:

Card Security Code:

Additional Security

This is a security measure to help prevent fraud.

If you have any questions about our trivia night please email us at wvpe@wvpe.org.