The document is an entry form for the Berlin Fair premium statement. It requests information from exhibitors such as name, phone number, address, age, last four digits of social security number, department and class numbers and descriptions from the fair book. Exhibitors must sign and date the form to receive premium payments for their entries to the fair.

1. BERLIN FAIR
ENTRY FORM – PREMIUM STATEMENT
(In accordance with Act 327, public Acts 1980 as amended)
**OPEN EXHIBITOR FORMS DUE TUESDAY, JULY 03, 2012
Exhibitor’s Name______________________________ EXHIBITOR NUMBER (4H only)________________
Phone Number______________ Age (youth only)_______
Address (street # , city, zip code) __________________________________________________________
__________________________________________________________
**NO PREMIUM CHECKS ARE MAILED. SEE PG. 7 OF THE FAIR BOOK FOR DETAILS**
Last four digits of Social Security # ________ (Open classes only) Used for exhibitor I.D.
(will be held in confidence by fair)
*Must have Department, Section and Class number as listed from the 2011 Berlin Fair Book*
DEPARTMENT SECTION CLASS CLASS DESCRIPTION
PLACING
NUMBER NUMBER NUMBER (As printed in premium catalog)
___For the financial benefit of the Berlin Fair, I choose not to receive any premium payment.
______________________________________________________ _________________________
Signature Date