Print out this form.

Fillout and send to the address at the end of form. If you have any questions you can E-mail your questions to APSEY.JON@ACD.NET

2000 Great Lakes Distance Riding Association

Distance Program Nomination Application

Rider Nomination Form

Name:_____________________________________________

Address:___________________________________________

City:__________________ State:________ Zip:___________

Phone: ( ____) _____________ Date:_____________

e-mail:____________________________________________

Nomination fee: $20.00 - this is a one time charge.

You can buy back mileage for $10 per year, for a maximum of 3 years.

Please send completed application and amount to:

Jon Apsey Phone: 1-517-349-5344

Circle "A" Ranch

5130 Okemos

East Lansing, MI 48823-2951

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