QTY

:

NAME:

SET:

COLL. #:

Black & White through Black & White--Boundaries Crossed
Player Name: ____________________________ Player ID: _______________________________ Date of Birth (MM/DD/YYYY): ___/___/______ Age Division (check one): Junior Division (born in 2002 or later) Senior Division (born in 1998, 1999, 2000, or 2001) Masters Division (born in 1997 or earlier)

Pokémon

City, State you are from: _______________________________
In addition to the card name and quantity of each card in your deck, we also require you to provide us with the set name and collector number of each Pokémon. This will help us ensure that each player is using a legal deck. If one of the cards in your deck comes from a set previous to Pokémon TCG: Black & White, but was reprinted in one of the sets listed below, put NA as the set name.

QTY:

NAME:

Trainer/Supporter/Stadium

Set Symbol Collector Number
ABBREVIATION SET NAME

SYMBOL

BLW EPO NVI NXD DEX DRX BCR TK PR MCD

Black & White Black & White--Emerging Powers Black & White--Noble Victories Black & White--Next Destinies Black & White--Dark Explorers Black & White--Dragons Exalted Black & White--Boundaries Crossed Black & White Trainer Kit
Black Star Promos BW01+

QTY:

NAME:

BASIC: SPECIAL:

Energy

McDonalds® Collection

ADMINISTRATIVE USE ONLY: Deck Checked by: ____ Random Check: Round ___ By ___ Top Cut Check by: ____