2010   MEMBERSHIP APPLICATION

WISCONSIN  LEGENDS RACING DIRT SERIES

NAME

 

ADDRESS

 

CITY

 

STATE

 

ZIP

 

PHONE

 

E-MAIL

 

CELL PHONE

 

  FAX

 

WEBSITE

 

PERSONAL

BUSINESS

SPOUSE

 

CHILDREN

 

OCCUPATION

 

CAR #

 

CAR COLOR

 

BODY STYLE

 

CAR OWNER(S)

 

CREW

 

SPONSORS

 

 

 

 

 

 

 

 

WEBSITE BIO - TELL US ABOUT YOUR PERSONAL, RACING AND/OR OTHER INTERESTS / ACCOMPLISHMENTS

 

 

 

 

 

 

I hereby certify that all statements and answers provided by me on this form are complete and true to the best of my knowledge.  Additionally, I fully understand that Legends Cars are dangerous and that participation in Legends Cars racing I hereby certify that all statements and answers provided by me on this form are complete and true to the best of my knowledge.  Additionally, I fully understand that Legends Cars are dangerous and that participation in Legends Cars racing could result in my being injured or killed.  Understanding this, I agree to hold harmless Wisconsin Legends Racing Dirt Series, Speedway Auto Mall & Speedway Legends, INEX Corp., 600 Racing, Inc., and any other companies, members, agents, or employees from liability resulting from racing a Legends Car.

 

 

Signature of Applicant                                                                                                                                                                         
Date :

Note:  We reserve the right to refuse eligibility to any person for any reason. 

INEX Division:      INEX Division:        Pro      Master     Semi-Pro

Membership Fee:   $75

Make checks payable to: Wisconsin Legends Racing Dirt Series

Mail form & payment to:                 
 Eric Barth 1003 Franklin St. Sauk City WI 53583