First Name        Last Name         
  
Email Address (IMPORTANT)

Company Name

Street Address             Unit
  
          City           State Zip/Postal Code
    
Voice Telephone Number                                
  If paying by check, please submit this form
Visa, MC, Discovery or Amex # and Exp. Date and mail check or money order to AWA
 
    
The Information below is to help keep track of 
  facilities where wallyball is played.
Name of Facility where You Play Wallyball

Contact First Name  Contact Last Name
   
Facility Street Address             Facility Unit
   
       Facility City      State  Zip/Postal Code
      
Facility Voice Telephone Number

Facility Fax Telephone Number

                   Thank You