Fillable Printable VA Form 0927e

VA Form 0927e

OMB Number: 2900-0759

Respondent Burden: 13 minutes

PARTICIPANT, COMPANION AND

VOLUNTEER FEES

NATIONAL VETERANS TEE TOURNAMENT

PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17,

Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use"

disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient

Databases - VA”. Providing the requested information is voluntary. However, you will not be able to participate in the event without

furnishing this information.

RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in

accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor,

and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time

expended by all individuals who must complete this application will average 13 minutes. This includes the time it will take to read

instructions, gather the necessary facts and fill out the forms.

PARTICIPANT'S NAME (Last, First, MI) COMPANION'S NAME

COMPANION VOLUNTEER

OR INFORMATION

RELATIONSHIP TO PARTICIPANT

ADDRESS (Street, City, State, Zip Code)

WORK TELEPHONE

NUMBER (Include area code)

HOME PHONE NUMBER

(Include area code)

CELL PHONE NUMBER

(Include area code)

IN CASE OF EMERGENCY, CONTACT

(Name, Last, First, MI)

WORK PHONE NUMBER

(Include area code)

HOME PHONE NUMBER

(Include area code)

RELATIONSHIP

COMPANION ACTIVITIES: $85

COMPANION LODGING:

NUMBER OF NIGHTS. IF SHARING A

ROOM WITH A PARTICIPANT, TIMES $35

PER NIGHT, PER ROOM

(Number of nights times $35 - TOTAL)

PARTICIPANT REGISTRATION FEE ($75)

TOTAL AMOUNT:

PLEASE RETURN THIS REGISTRATION FORM WITH YOUR CHECK/MONEY ORDER FOR

THE APPROPRIATE FEES (Do not send cash). MAKE CHECKS PAYABLE TO:

MAIL TO:

VA FORM

FEB 2014

0927e

2014