Please Mail Form & $30 Fee to:
Nevada Speedway
14416 S. 1400 Rd
Nevada,MO 64772
(This Fee Will Go Into Driver's Point fund)
Office Use: Date Paid __________ Check # __________ Cash __________
CIRCLE CLASS: LATE MODEL - MODIFIED - STREET STOCK - FACTORY STOCK - B MOD
DRIVER INFORMATION
Car # ___________ Driver: ______________________________________ Jacket Size: ______
SSN # _____/_____/________ Fed I.D. ______-_____________ Birthdate: ______/______/________
Street Address: __________________________________
City: ________________________________ State: _________ Zip: ____________________
Phone: ( ) ______-__________ E-Mail: ______________________________________________
Years Racing: ______ Spouse: _____________________________
OWNER INFORMATION (If different from driver)
Owner's Name: ______________________________________
SSN/FED I.D. _______________________________________________
Owner's Phone # - day ( ) ______-__________ night ( ) ______-__________
Owner's Address: ___________________________________________________
City: ________________________ State: ________ Zip: ________________
EMERGENCY CONTACT
EMERGENCY CONTACT NAME: __________________________________________________
PHONE # ( ) ________-______________
IS THERE ANY MEDICAL REASON YOU SHOULD NOT BE RACING: __________________________
LIST MEDICAL ALERTS: (i.e. Contact Lens) ________________________________________________
DO YOU HAVE HEALTH INSURANCE ? ___________________
Driver's Signature ________________________________ Date ________________________
IMPORTANT: Who is to recieve 1099 & Point Money at the end of the year ?
(Please Circle Only One ! - If none or both are circled it will go to the driver !)
POINT MONEY - Driver or Owner 1099 - Driver or Owner