Eastern Regional Championships Payment Form

STATE INFORMATION

State Association *

CONTACT INFO

First Name *

Last Name *

Email *

Phone Number *

SELECT PAYMENT AMOUNT

SELECT YOUR STATE FROM BELOW. THE AMOUNT SHOWN IS A COMBINATION OF TEAM FEES WILDCARD PAYMENTS

Select State: *

PAYMENT INFORMATION

Billing First Name *

Billing Last Name *

Billing Address 1 *

Billing Address 2

Billing City *

Billing State *

Billing Zip *

Cardholder Name *

Card Type *

Card Number *

Exp Date *

Security Code (CID/CCV2) *

Total:

Does not include additional taxes, fees and surcharges.

Refund Policy: Non-Refundable

* Indicates Response Required