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2012 Plymouth Speedway Drivers Registration Form
11631 W. 12th Road Plymouth, IN 46563 (574) 936-0900
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Circle One:
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Drivers Name: __________________________________________________________
Car # ___________
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Street Address: __________________________________________________________________________
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City: _______________________________________ State: _____________
Zip Code: ________________
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E-Mail Address: _________________________________________________________
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Home Phone: (______) _______________________ Work Phone: (______
) __________________________
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Are you at least 16 years old? (Circle One)
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2012 Rookie of Year Candidate? (Circle One)
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Social Security or Tax I.D. Number of person or Entity is Mandatory
for 1099s* (Payoff Checks Made Out To)
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Name of Entity: __________________________________________________________________________
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Address: _______________________________________________________________________________
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City: _________________________________________ State: _____________
Zip Code: _______________
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Phone: (______) ____________________ SSN or Tax I.D. No.: ____________________________________
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Signature: _____________________________________ Title (If Corp.)
______________________________
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Driver / Car Information
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Vehicle Make: ___________________ Year: _________ Model: _________________
Color(s): ____________
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Sponsors: _______________________________________________________________________________
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_______________________________________________________________________________________
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Years Racing: _________________ Number of Championships: _____________________________________
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Optional Information
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Occupation: ______________________________________________________________________________
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Hobbies: _________________________________________________________________________________
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Married: (Circle One)
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Spouses Name: _________________________________________________________
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Disclaimer: I understand that my signature here makes me a member
of the Plymouth Speedway. I agree to abide by the racing rule book
of Plymouth Speedway and its interpretation by officials. I hereby
give my permission to use photographs of myself and/or race car
as part of their racing publicity promotions. I agree not to hold
Plymouth Speedway responsible for disqualification or damage to
either car or driver and I agree that I consider the track is in
safe racing condition when I take part in any racing activity.
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*Note: Checks will be made payable to the person listed on your
registration form as the recipient of the 1099.
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Signature: ___________________________________________________
Date: ________________________
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