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REGISTER TO COMPETE

Buggy Name
Buggy Number
Owner
Email Address
Sponsor
Street Address
City
State Province
Zip/Postal Code
Home Phone
Business Phone
Buggy

Class

4 Cyl Jeep
1,2,3 & 4 Cyl AC
4 Cyl, 2 or 4 WD
6 Cyl, 2 or 4 WD
Stock V8, 2 or 4 WD
Modified 4 WD
Pro Modified
Only seven persons per buggy allowed in pits. Please print all their names here. Signatures will be required on a release form at time of registration. No one under 16 years of age is allowed in the pits. Minors must have parent or guardian sign the release form
Driver and Age $50 $60
Crew #1 and Age $20 $30
Crew #2 and Age $20 $30
Crew #3 and Age $20 $30
Crew #4 and Age $20 $30
Crew #5 and Age $20 $30
Crew #6 and Age $20 $30
PURSE PAYMENT INFORMATION
Prize money to be paid to:
Name
SS# or Tax ID#
Street Address
City
State Province
Zip/Postal Code
Home Phone
Business Phone
Credit card number
Credit card type Visa MasterCard
Expiration date
Name on card

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