2024 State Qualifying Trail - Boater Entry Form Sunday, April 7th (Smallwood) Sunday, May 19th (Dundee) Saturday, June 22nd (Conowingo) Saturday, September 21st (Youghiogheny Lake) Boater Full Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Boater Email* Cell Phone*Chapter Club* B.A.S.S. Number* B.A.S.S. Expiration* Notify me of tournament information via:* Email Phone Number Boat InformationYou are responsible for providing your own boat for this tournament:Boat Year and Model* Motor Brand* Horsepower* State Boat Registration Number* Exp. Date of Insurance* Upload proof of insurance to include $300,000 limited liability coverage* Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 100 MB. Co-Angler Linked Partner:Co-Angler Full Name First Last Club Chapter Name Email Cell PhoneBoater Only Registration Payment2024 State Qualifying Trail Boater Fee* Price: Select a Payment Method* Credit Card Paypal You will be directed to PayPal to complete your PayPal payment after your select ‘Register’ at the bottom of the form.Credit Card*Card Details Cardholder Name Indicate your concurrence*• I have acquainted myself with the Maryland BASS Nation Tournament Official Rules (See Standing Rules document available at www.mdbassnation.com). • I have completed this application fully and am submitting my registration for and entry fee to the Maryland BASS Nation via the online application & payment process. • I hereby agree to be bound by, and comply with, all tournament rules and regulations. I expressly assume all risks associated with the tournament and I hereby release the Maryland BASS Nation, the host, sponsors, tournament officials and volunteers from all claims of death, injury, and/or property damage incurred by me in connection with my participation in the tournament. The use of a polygraph test will be made available and put to use if deemed necessary. I also certify that I am a member in good standing with B.A.S.S. • I agree to provide a current copy of my boat insurance document(s). A $300,000.00 Boating Liability minimum is required. If insurance renews during the tournament season or you purchase a new boat an updated copy must be provided to the Tournament Director, ASAP.) (If you fished last year and we have a current “unexpired” copy on file, it is not required to resend at this time). Email insurance documents to: mdbassnation4@gmail.com and don.bronson@comcast.net • I understand that I am required to report tournament winnings to the IRS as taxable income, and that the Maryland Bass Nation will provide an IRS form 1099 to me if I qualify. I will completed this form fully (including my social security number), and understand that this information will only be used for the purpose of filling out IRS form 1099. The Maryland Bass Nation will safeguard this information in accordance with the privacy act of 1974. I understand and agree to the following statements Δ