BACK                                              ENTRY FORM

DK VALIANT RACE Bike

Name _____________________________________________________________

Address ____________________________________________________________

City _____________________________     State ______________ Zip__________

Phone Number  _______________________________________________________

------------------------------------------------------------------------------------------------------------- 

Send a Check or Money order to 

                                   Care of Champion City BMX BIKE RAFFLE

                                                       111 S. Main Street

                                                     Urbana, Ohio 43078