Entry Form

Circle class entering:  MODIFIED MINI CAR     STOCK MINI CAR      STOCK TRUCK     
                                                 MINI VAN                       WIRE          TRUCK

Indicate Race Location & Date: ________________________________________________

Driver's Name: ______________________________________  Date of Birth: ___________________

Driver's License Number: _______________________________________________

Social Security Number: ________________________________________________

Address: ____________________________________________________________________

City: _____________________  State: ______  Zip: _______________

Home Phone: _____________________  Work/Cell Phone: ______________________

Number Requested: _______  Year/Make/Model: _____________________________________

Color of Car: ________________

I have received a copy of all rules and regulations and agree to abide by all said rules as stated. I further grant Ramer Race Promotions permission to use
my name and likeness as captured on photo or videotape in any advertising or promotional material they produce.


Signature of Driver: ___________________________________________________

Date: _______________   Amount Paid$: ______________________