CLUB NAME: _______________________________________________

Choose Request:  1) Deposit to NVWF                          2) Check from NVWF 

Amount:  __________________________________________________

Reason:  __________________________________________________

(include copies of contracts or receipts)

Payable to: _______________________________________________

Date: ____________________________________________________

Mailing Address:  __________________________________________

Contact Name & Phone Number: ____________________________

Send this form;

1) alone with your club’s registration check for deposit*      …OR FOR

2) reimbursable with receipt, 3) $750.00 Host Fee two weeks before your meet date, and

a separate form for 4) the $300.00 athletic trainer fee to:

NVWF Treasurer

c/o James Zoller

6329 Bob White Drive

Warrenton, VA 20187

(*This form is used to send or request monies only, do not send with Registration Forms.)