Registration Fee $25.00 before Play Day
Thereafter Fee $30.00
2010
Dirtona Raceway Date_______________
Car Registration Fees Paid___________
___Hobby/Thunder ___Super Stock First Choice Car #______
___IMCA Stock ___IMCA Modified Second Choice Car #____
___Factory ___305 Rebel Sprint Third Choice Car #_____
Name:_______________________________________________________
Address:_____________________________________________________
City:________________________ State:_________________ Zip:_______
Phone;_______________________ Cell #___________________________
Drivers’ Birth Date__________________ Social #:____________________
Car Owner:___________________________________________________
Spouse’s Name:________________________________________________
In case of emergency____________________________________________
Phone #:_____________________________________________________
If 1099 Tax Form is to be sent other than you, Please give information.
Name :_______________________________________________________
Address;_____________________________________________________
Phone #: _______________________ Social #:______________________
Drivers Signature:______________________________________________
