Humboldt Speedway in 2010!

Car and Driver Registration Form

Please Mail Form and $30 Fee to 8065 Hwy. 39 Chanute, Ks 66720

                                          

Office Use: Date Paid__________Check#_________Cash_________

DIVISION_______________________     CAR#_______________

DRIVER INFORMATION 

Please Print All Information Clearly

DRIVER:______________________________________________________________

ADDRESS:_________________________ CITY:________________ STATE____ ZIP______

HOME PHONE:__________________________ CELL PHONE:_______________________

E-MAIL:_________________________________ BIRTHDATE:________________________

SOCIAL SECURITY NUMBER (or) FEDERAL ID NUMBER:___________________________

                   HOW MANY YEARS RACING:___________ JACKET SIZE:________

                                  WHO IS TO RECIEVE 1099: Driver Or Owner

OWNER INFORMATION

NAME:_____________________________________________________________________

                                    (If 1099 Goes To The Driver Do Not Answer The Following)

ADDRESS:_______________________CITY:_______________STATE_____ZIP_________

HOME PHONE:________________________CELL PHONE:__________________________

SOCIAL SECURITY NUMBER (or) FEDERAL ID NUMBER:___________________________

                              OWNERS SIGNATURE:____________________________

  

                 All 1099 Forms Will Be Sent To Driver Unless Information Above Is Filled Out

           And Signed. There Will Be No Changing Info. After December 31st For Tax Purposes

EMERGENCY CONTACT NAME___________________________ PHONE__________________RELATIONSHIP________

Is There Any Medical Reason You Should Not Be Racing:____ Do You Have Health Insurance:_______

DRIVERS SIGNATURE:____________________________________DATE:____________