Please fill out, print, include payment and mail to
LI HOOPS • P.O. Box 723 • East Northport, NY 11731-1204
or Fax with credit card info to: Fax 631-239-6037
Name
Address
City
State
Zip
Phone
- -
DOB
Cell
Please circle the division you prefer:
(Elite-A) (A1) (B1) (B2)
Sunday evening
Women’s League
Team: $800 Men/Women $500
Free Agent:
$120 men/$70 women
MC/Visa #
Exp date
Sign
Early payment team discount of $50 if paid by April 21
Credit card payments processed by Midnight Hockey, Inc.
Amount
