2012 Plymouth Speedway Drivers Registration Form
11631 W. 12th Road Plymouth, IN 46563 (574) 936-0900

Circle One:

Driver’s Name: __________________________________________________________ Car # ___________

Street Address: __________________________________________________________________________

City: _______________________________________ State: _____________ Zip Code: ________________

E-Mail Address: _________________________________________________________

Home Phone: (______) _______________________ Work Phone: (______ ) __________________________

Are you at least 16 years old? (Circle One)

2012 Rookie of Year Candidate? (Circle One)

Social Security or Tax I.D. Number of person or Entity is Mandatory for 1099’s* (Payoff Checks Made Out To)

Name of Entity: __________________________________________________________________________

Address: _______________________________________________________________________________

City: _________________________________________ State: _____________ Zip Code: _______________

Phone: (______) ____________________ SSN or Tax I.D. No.: ____________________________________

Signature: _____________________________________ Title (If Corp.) ______________________________

Driver / Car Information

Vehicle Make: ___________________ Year: _________ Model: _________________ Color(s): ____________

Sponsors: _______________________________________________________________________________

_______________________________________________________________________________________

Years Racing: _________________ Number of Championships: _____________________________________

Optional Information

Occupation: ______________________________________________________________________________

Hobbies: _________________________________________________________________________________

Married: (Circle One)

Spouse’s Name: _________________________________________________________

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.

*Note: Checks will be made payable to the person listed on your registration form as the recipient of the 1099.

Signature: ___________________________________________________ Date: ________________________