PLEASE PRINT

AUCTION REGISTRATION # ________ Date: _____________

By registering, I agree to the Terms and Conditions of this Auction. I understand court

action In Brevard County will be taken should any violation occur. Returned Check

Policy: I will reimburse Auctioneer three (3) times the amount of any returned check

and am liable for all collection, legal fees, court costs and Interest Incurred.

Bidder’s Name:_____________________________________ Dr. Lic. No.:__________________

Company Name: If any, _______________________________________________________________________

Physical Address (No P0. Box#) ___________________________________________________

Mailing Address (If different from above)______________________________________________

CITY: _________________________________________STATE: _______ ZIP CODE: _________________

TELEPHONE NUMBERS: Area Code __________ Number (Home) ________________________

Area Code ___________ Number (Office) _________________________

Area Code ___________ Number (Cell) __________________________

COMPLETE PAYMENT DUE TODAY, (unless otherwise noted) in:

Certified Check, Personal or Company Check with letter from bank verifying funds. U.S. Wire Transfer will incur a $20.00 charge/International $35.00 charge

Bank Name _________________________________

Address ___________________________________

Account # __________________________________

Phone _____________________________________

Contact Name _______________________________

How did you hear about this Auction? ___________________________