2012 Driver Registration Form by 8Hp08vI3

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									         2012 Dirt Tour Registration Form

Driver's Information

Driver's Name: ___________________________________ Date of Birth: ____/___/_______
Address:________________________________ Age _____________
City/State/Zip: _____________________________QMA Driver # __________________
Club/Home Track: _________________________________________________
List Classes:

Class: _____________________ Class: ______________________ Class: ______________________



Handler's Information

Name: __________________________________ Relationship to Driver: ________________
Address:________________________________ City/State/Zip: _______________________
E-mail: _________________________________ QMA Handler #______________________
Daytime Phone: _________________ Evening Phone: _________________ (include area code)


Registration Details


Registration for the series will be $40 per car up to the morning of the first event. Anyone
signing up after the first event will be required to pay $75.00 per car and sign-ups will be
closed after the third “Series” event.

Please make checks, cashier's checks, money orders payable in U.S. dollars and mail to Gary Bozowski at:

Gary Bozowski
38 Nurko Rd.
Millstone, NJ 08535

Questions: e-mail bozowskifamily@verizon.net or call (908) 239-8105

FOR SERIES USE ONLY
 Check No._________
 Amount___________
 Date Rec'd_________

								
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