Last Name  _____________________ Age at 31/12/97 ____

First Name _____________________ Male / Female

Address    ___________________________________________


           ___________________________________________
 
Post Code  _______________ Tel No. ___________________


Club _______________________ Reg No. _________________

I certify that the above details are correct and
that I will abide by the promotors conditions.


Signed _____________________________ Date ____________

Cheques payable to Staffordshire ASA.

_____ 25 metre events @ £1.50 = ___________

_____ Other events    @ £2.00 = ___________

                        Total   ___________

Please enclose S.A.E. for the return of cards.
PTO for programme and entry times


          Session 1 1O.OOam
                                 Time
Event 1 Mens 25m Backstroke     ___ ____.___
Event 2 Ladies 25m Backstroke   ___ ____.___
Event 3 Mens 50m Butterfly      ___ ____.___
Event 4 Ladies 50m Butterfly    ___ ____.___
Event 5 Mens 50m Breast         ___ ____.___
Event 6 Ladies 50m Breast       ___ ____.___
Event 7 Mens 25m Freestyle      ___ ____.___
Event 8 Ladies 25m Freestyle    ___ ____.___
Event 9 Mens 4 X 1 I.M.         ___ ____.___

         Session 2 Approx 2.30pm

Event 10 Ladies 4 X 1 I.M.      ___ ____.___
Event 11 Mens 50m Freestyle     ___ ____.___
Event 12 Ladies 50m Freestyle   ___ ____.___
Event 13 Mens 25m Breast        ___ ____.___
Event 14 Ladies 25m Breast      ___ ____.___
Event 15 Mens 50m Backstroke    ___ ____.___
Event 16 Ladies 50m Backstroke  ___ ____.___
Event 17 Mens 25m Butterfly     ___ ____.___
Event 18 Ladies 25m Buttertly   ___ ____.___
RefST
  Return to: Tony Ward,103 Crowther Road,
              Wolverhampton. WV6 OHX.