2018 SUPER CRUISE MERCHANT PICK AWARDS 2018 SUPER CRUISE MERCHANT PICK AWARD PAYMENT FORM Merchant Pick Award Plaque $50/Each (Online payment will continue thru February 17, 2018)Unique IDPURCHASED BYFirst Name*Last Name*Company, Business, Club, or OrganizationAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email-will be used to send your verification back to you* Phone*EVENT SPONSORINGAre you interested in being a Sponsor/Supporter of the event?(Optional) Yes, I am interested in being a Sponsor/Supporter of the event, contact me. AWARD PLAQUE INFORMATIONHow do you want your name or business to be printed on plaque(s) as award sponsor, fill in below?*> Tell us how your name is going to be spelled on the plaque(s).Do you want to pick your merchant plaque recipient or do you want us to do it for you?*I will attend event and pick recipientPlease have BCCC pick recipient for mePAYMENTMerchant Pick Awards*> $50/each plaque Price: $50.00 Quantity: Total $0.00 Select Payment Method*Select belowPayPalCredit CardWhen you click the Submit button you will be directed to PayPal to complete your purchase!Credit Card*> This is a secure SSL encrypted payment. American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Liability Release: In consideration of the acceptance to participate. Entrants, participants, spectators and/or riders release and discharge BCCC, Inc. its officers, agents, representatives, directors, volunteers, servants, sponsors, affiliates clubs, sponsors, vendors, Fred Hall/Cal Shows, Kern Co. Fairgrounds and all owners and management of Kern Co. Fairgrounds and any and all clubs and organizations affiliated with BCCC or Kern Co. Fairgrounds from any and all known or unknown causes whatsoever that may be suffered by anyone participating in this event to his/her person or property. Event Management reserves the right to restrict entrants and/or their guests to behavior deemed acceptable during all activities of this event, including eviction should it become the opinion of event management that it is in the interest of safety, and/or proper behavior. The undersigned entrants acknowledge by his/her submission as having read and understood the above release of liability and waives all claims as outlined within. Liability release to include all passengers. Rain or Shine Event.NameThis field is for validation purposes and should be left unchanged.