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October 5 & 6, 2007
(one form per registration)
DRIVER INFORMATION
Name:
___________________________________________________________________________________
Address:_________________________________________________________________________________
City:______________________________________________
State: ____________Zip:_________________
Phone # (_______)
_______________-_______________________________
OWNER INFORMATION
Checks paid to car owner
Car Owners Name:
________________________________________________________________________
one name only
CAR #____________________
Address:
_________________________________________________________________________________
City:
_____________________________________________State: ____________Zip:
__________________
Phone # (_______)
______________-_______________________________
Social Security #:
_________________-_________-___________________
checks issued only with social security number
MAKE CHECKS PAYABLE TO:
Marysville Raceway Park
P. O. Box 6209
Marysville, CA 95901
BEFORE Sept. 15, 2007 $100.00 (driver & car
only)
AFTER Sept. 15, 2007 $150.00 (driver & car only)
Pit Passes $37.00
DRIVER ONLY - INSURANCE
BENEFICIARY INFORMATION
Name:
____________________________________________________ Relationship:
___________________
Address:
_________________________________________________________________________________
City:
_________________________________________________ State:
___________Zip: ______________
Social Security #:
_______________-____________-_____________________
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