FAX this form to 1-419-754-2253

___ Enclosed is my check, money order or credit card order NOW for only $600 $497 (one time billing). Only 20 spots available

___ Enclosed is my check, money order or credit card order NOW for only $450 $250 (per month). Only 5 spots available

Totaling $__________________.00

Charge my (Note - You can use more than one card to complete this order):

Visa, MasterCard, American Express

Card Number:_____________________________________________ Exp. Date:______________

Signature: __________________________________________

Print Name: _______________________________________________________________________

Address 1: _________________________________________________________________________

Address 2: _________________________________________________________________________

City: ______________________________________ State: __________________________________

Zip Code: ______________________________ Country: __________________________________

Player’s name: ______________________________________________________________

Position: ____________________________________________________________

Telephone: __________________________________________________________

Year/grade: __________________________________________________________

E-Mail: _____________________________________________________________

Or Mail This Form To:

Vince Palko Enterprises, LLC
7051 Ramblehurst Dr.
Sylvania, OH 43560