Va Form 0927b - Participant Registration Application
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2OMB Number: 2900-0759
Respondent Burden: 20 minutes
PARTICIPANT REGISTRATION APPLICATION
NATIONAL VETERANS TEE TOURNAMENT
DEADLINE:
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 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
NAME (Last, First, MI)
SOCIAL SECURITY
DATE OF BIRTH
GENDER
NO. (Last 4 digits only)
MALE
FEMALE
ADDRESS (Street, City, State, Zip Code,
DAYTIME TELEPHONE
EVENING TELEPHONE
and County)
NUMBER (Include area code)
NUMBER (Include area code)
NAME TAG PREFERENCE
E-MAIL ADDRESS
PRIMARY VA MEDICAL CENTER
(City & State)
PLEASE INDICATE YOUR T-SHIRT SIZE
SMALL
MEDIUM
LARGE
XL
XXL
XXXL
OTHER
WHAT BRANCH OF SERVICE WERE YOU IN?
AIR FORCE
ARMY
MARINE CORPS
NAVY
COAST GUARD
OTHER
WILL YOU BE ACCOMPANIED BY A TRAINED/CERTIFIED ASSISTANCE DOG?
YES
NO
WILL YOU REQUIRE A DOG SITTER?
YES
NO
INDICATE ANY NEED FOR SPECIAL TRAVEL ASSISTANCE UPON ARRIVAL OR DEPARTURE. ALL PARTICIPANTS
ARE ENCOURAGED TO BRING THEIR OWN ASSISTIVE EQUIPMENT. ALL PARTICIPANTS MUST BRING THEIR
OWN MEDICATIONS.
ARRIVAL DATE AND ESTIMATED ARRIVAL TIME
TRAVEL MODE (Select one)
OWN VEHICLE
AIR
BUS
VANPOOL
IF YOU ARE NOT PLANNING TO STAY AT THE EVENT HOTEL(S), INDICATED WHERE YOU WILL BE STAYING.
(Include: Name, Street, City, State, Zip Code, and Phone Number)
IN ORDER TO HELP US ASSIGN YOU TO THE OPTIMAL GOLF GROUP AND PROVIDE ADEQUATE INSTRUCTION
FOR YOUR GOLF NEEDS, PLEASE LET US KNOW THE FOLLOWING
RIGHT HANDED
LEFT HANDED
DO YOU GOLF?
HAVE YOU EVER GOLFED BEFORE?
YES
NO
(If "No", skip the next two questions
ARE YOU BRINGING YOUR OWN GOLF CLUBS?
YES
NO
0927b
VA FORM
JAN 2013
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