Plymouth Speedway - 2013 Drivers Registration Form

2013 Plymouth Speedway Driver Registration Form
[ print form in two (2) pages ]

Class (circle one):

Modified

Super Street Stock

Pure Thunder Stock

600 Restrictor

600 Wing/Non-Wing

Driver’s Name: ___________________________________________________________________________________________________

Street Address: __________________________________________________________________________________________________

City: ____________________________________________________________ State: _______________________ Zip: ______________

E-Mail Address: ___________________________________________________________________________________________________

Phone: ( ______ ) __________________________

Are you at least 16 years old?

Yes

2013 Rookie of Year Candidate?

Yes

INFORMATION FOR: SOCIAL SECURITY OR TAX I.D. NUMBER OF PERSON OR ENTITY TO RECEIVE 1099 (PAYOFF CHECKS MADE OUT TO)

Name or Entity: _____________________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________________

City: __________________________________________________________________ State: ____________________________ Zip: _____________

Phone: (_________) ___________________________________________

SSN or Tax I.D. No.: ________________________________________________________________________________________________

Signature: ________________________________________________________________________________________________________

(Title if Corp) ______________________________________________________________________________________________________

Disclaimer: I understand that my signature here makes me a member of 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: _______________________________

Web and Media Form

Car Number # ________________

Class (circle one):

Modified

Super Street Stock

Pure Thunder Stock

600 Restrictor

600 Wing/Non-Wing

Driver’s Name: _____________________________________________________________________________________________________

Nickname: ________________________________________________________________________________________________________

Number Of Years Racing: ___________________ Championships: ___________________________

Hometown: ________________________________________________________________________

Chassis Manufacturer: _______________________ Engine Builder:___________________________

Racing Accomplishments: (Tracks raced, races won, track records, Series raced in) ________________________________________________

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Sponsors: ________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Misc Info: _________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Email Address: _____________________________________________________________________________________________________

Website Address: ___________________________________________________________________________________________________