X - The US Amateur Championship

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2011 WINNERS Last year these outstanding men and women exemplified the skill, determination and endurance it takes to be Champions at the U.S. Amateur Championship. Mens Division Champions (Back Row, L to R): Will Haagensen – 4th Place, Ron Park – Runner-Up, Ernesto Bayaua – Champion, David Uwate – 3rd Place, Pete Ziemak – 5th Place, Criegh Dumo – 5th Place Womens Division Champions (Front Row, L to R): Lenore McCarthy – 3rd Place, Suzanne Smith – Champion, Jamie Toennies – Runner-Up
U.S. AMATEUR OFFICIAL ENTRY FORM Check tournament site choice—September 21-23, 2012. We will make every effort to send you to the site of your choice. If you do not check your site of choice or a site does not have enough participation to qualify for a Preliminary Round, you will be sent to your second location choice or the site closest to you. Please indicate a 1st and 2nd tournament site choice. DETACH HERE 1st 2nd 1st 2nd 1st 2nd Please print all information clearly and be sure to sign this entry form. First Name Middle Initial Last Name Street Address Daytime Phone County Email Address I understand the APA may contact my employer to verify my employment. Sponsor Address By my signature below, I certify that I have conscientiously inspected and completed this entry form. I have read and fully understand the rules for entering the U.S. Amateur Championship. I understand that this is a prestigious event that does not award any prize money. Further, I certify that I am of amateur standing, do not posses any professional characteristics (as described in Rule #9) and am not a member of any professional billiards association or group. X Signature (Required) Date ( ) ( ) City State Zip Code Evening Phone Month Birthdate Day Year Employer Employer Contact Sponsor Name Huntsville, AL BUMPERS BILLIARDS Phoenix, AZ BULLSHOOTERS Mens Division Only Mountain View, CA SHORELINE BILLIARDS Rancho Cucamonga, CA STIX BILLIARDS Fort Collins, CO MATCH-UP’S Southington, CT SHOOTER’S BILLIARDS Mens Division Only Windsor Locks, CT POOL TABLE MAGIC Womens Division Only Fort Pierce, FL AMY’S BILLIARDS Palm Harbor, FL STROKER’S Championship Location Male Female Tallahassee, FL ZINGALES BILLIARDS Sept. 28-30 Atlanta, GA MR. CUE’S II Addison, IL PYRAMID CLUB New Iberia, LA EMERALD BILLIARDS Silver Spring, MD GALAXY BILLIARDS Mooresville, NC 150 N OUT Sept. 14-16 Raleigh, NC BRASS TAP & BILLIARDS Cherry Hill, NJ BREAKERS Columbus, OH 8-BALL SPORTS BAR & BILLIARDS Check box if you would prefer all tournament information be emailed to you. Columbus, OH 8-BALL SPORTS BAR & BILLIARDS Mens Division Only - Sept. 28-30 North York, ON SHOOTERS BILLIARDS Salem, OR CUE BALL Greenville, SC WORLD CUP BILLIARDS Memphis, TN HIGH POCKETS Mens Division Only Houston, TX BOGIE’S BILLIARDS Mens Division Only Round Rock, TX SKINNY BOB’S Midlothian, VA DIAMOND BILLIARDS Entries must be postmarked by June 15, 2012. $ 4 0 Entry Fee APA Member Number $ 5 0 Non-APA Member Entry Fee ( ) Employer Contact Person Phone ( ) Sponsor Phone (MUST BE COMPLETED FOR APA ENTRY FEE) Detach, complete form, sign and return with check or money order made payable in U.S. funds to American Poolplayers Association. Mail to: American Poolplayers Association, Inc. • 1000 Lake Saint Louis Blvd. • Suite 325 • Lake Saint Louis, MO 63367-1387. Entry form available online at usamateurchampionship.com. Entry fee for APA Members is $40. Entry fee for Non-APA Members is $50. APA will confirm receipt of this entry within two weeks of receiving.
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