Driver License Copy Template - PDF

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					                                                                2011 WISSOTA AMSOIL Dirt Track Series
                                                                  Competitor’s License Application
       OFFICE USE ONLY
                                                                                    Required information. Complete ALL Blanks.
  License Number 11- ________
                                                                     PLEASE type or legibly print all answers to fill in all the blank spaces completely with the appropriate information
  Paid With Check # __________                                                            to ensure that all your WISSOTA points will be posted to your name.
  If Temp, Check Here ________                                                        Complete information is required - please complete every blank. Thank You!



DRIVER’S LAST NAME____________________________________FIRST_______________________________INITIAL ____________
NICKNAME __________________________________________________________________________________________________________
MAILING ADDRESS (House Number or P.O. Box) ________________________________________________________________________
CITY______________________________________________________STATE___________________ZIP ______________________________
            MY ALL THE DIRT SUBSCRIPTION PREFERENCE IS:                                                                       q ONLINE VERSION                                     q PRINT VERSION
q      I AM LICENSED IN MORE THAN ONE DIVISION. PLEASE SEND MY ADDITIONAL ATD SUBSCRIPTION TO:
             If you are licensed in more than one division, you may have your “additional” subscription(s) sent to someone else. If you would like to do this, check below and include the name and address information.

            ______________________________________________________________________________________
            Name                    Address                 City                 State    Zip
EMAIL ADDRESS:                           ______________________________________________________________________________________________________________________________________________________________


DRIVER’S SOC. SEC. NO._____________________________________DRIVER’S PHONE (________) ________________________
DRIVER’S AGE:________ DATE OF BIRTH: MONTH_________________________ DAY_________________ YEAR ____________
             If driver is under 17 years of age, a certified copy of driver’s birth certificate must be sent along with this license application. If it is not sent, the license will not be processed. Please see #13 below.
CHECKS PAYABLE TO:_______________________________ SOC. SEC./FED. I.D. # ______________________________________
CLASS OF CAR____________________________________CAR NUMBER____________________YEARS RACED ______________
CHASSIS BRAND/BUILDER ________________________________________________________________________________________
                                  To Determine If You Have Raced In A “Higher” Division, Please Refer To The Official List Of WISSOTA Divisions On The Back Of This Form
q       ROOKIE STATUS                          (Check Only If You Raced 5 Or Fewer Shows In This Class Or A Higher Division With WISSOTA Or Any Other Sanction In Any Previous Year)

FEE BEING PAID                       (See Other Side)   $________________(US Funds Only)                                    JACKET SIZE: S                              M        L        XL        XXL         XXXL            (Circle One)


q       PATCHES               (Check Here If You Need Us To Send WISSOTA and/or Sponsor Patches For Your Drivers Suit. If You Have All Patches, Please Do Not Check Box.)

q       CHECK HERE IF YOU USE SUNOCO OR TURBO BLUE RACING GAS

     “I do agree, by signing this WISSOTA competitor’s license application form, that I will abide by all the rules and regulations set forth by WISSOTA, including, but not limited to, the following:
     1. I have, or will have, familiarized myself with all the WISSOTA rules and regulations, including car specifications and safety rules, and I specifically agree to abide by all the WISSOTA rules, including all rules and regulations
printed in WISSOTA’s annual rule book, as well as WISSOTA’s modifications, clarifications and any new prescribed rules posted on WISSOTA’s internet website and/or in All The Dirt! Racing News.
     2. I agree that I shall be the sole spokesperson for myself, the car owner, and the crew in all matters pertaining to compliance with the rules and regulations and I agree and understand that I am responsible for the conduct of my
crew.
     3. I agree and understand that by submitting my race car for various technical and safety inspections, I certify that the race car meets all the rules and regulations for participation in WISSOTA sanctioned events, and I
understand that the burden of proof will rest upon me to show that I am in compliance with all of the WISSOTA rules and regulations, and I understand violation of various rules can result in a fine, suspension and loss of all
national, all regional and all track points.
     4. I agree to appropriately use all required stickers, decals and patches and I understand that failure to do so will result in loss of points and forfeiture of all money and awards for the event.
     5. I agree that all decisions of WISSOTA race officials, or track officials, regarding the interpretation and application of the WISSOTA rules, and the scoring of positions, shall be non-litigable. I further covenant and agree that I
will not initiate any type of legal action against WISSOTA, or a WISSOTA promoter, to challenge such decisions, to seek monetary damages, to seek injunctive relief or to seek any other kind of legal remedy. I understand that if I
pursue any such legal action, which violates this provision, then I expressly agree to reimburse WISSOTA, or the WISSOTA promoter, for all of its attorney’s fees and costs in defending against such legal action.
     6. I agree to release all advertising and promotional rights to my name, car and likeness to WISSOTA, its sponsors and affiliated media including, but not limited to, All The Dirt! Racing News.
     7. I understand that all points, awards and money earned will be paid to the driver.
     8. I further understand that there is no express or implied warranty of safety resulting from publication or compliance with the WISSOTA Late Model, Modified, Super Stock, Midwest Modified, Street Stock, or Mod Four rules and that
they are intended as a guide for the conduct of the sport and are in no way a guarantee against injury or death to participants, spectators or others.
     9. I understand that I am an independent contractor and am not an agent or employee or WISSOTA or any WISSOTA sanctioned race track. I further understand that as an independent contractor I am solely responsible for com-
pensating my employees, agents or pit crew members. I also assume full responsibility for reporting or filing any reports or tax returns with the appropriate authorities on any or all earnings or funds received as a result of my partici-
pation in WISSOTA sanctioned racing events, including, but not limited to, Federal Social Security taxes, Federal income taxes, State income taxes, Federal and State withholding taxes, unemployment taxes and workers compensation
insurance.
     10. I certify that I have not been convicted of or pled guilty to any crime, including but not limited to, use of illegal drugs, during the one year prior to the date of this application. I understand that if I have been convicted of or
have pled guilty to any crime in the past, such guilty plea or conviction may be sufficient reason to have this license application rejected by WISSOTA.
     11. I understand that $16.25 of my annual licensing fee is being used for a subscription to All The Dirt!, the official newspaper of record for WISSOTA, so that I can be kept up-to-date on important information regarding WISSO-
TA racing. This subscription will begin when the ATD office receives a copy of my license form from the WISSOTA office. If I hold a license in more than one division, I can direct my additional subscription(s) to another individ-
ual(s) or location by properly indicating that individual or location above. I understand that I may choose either the print or online delivery method of All The Dirt.
     12. I understand that from time to time, WISSOTA and its sponsors and partners may send emails to me that contain information on WISSOTA or products and services available to me as a racer.
     13. I understand that if I am under 16 years of age, I can only be issued a restricted license, which means I may not be allowed to compete at all WISSOTA member tracks. I understand it is my responsibility to contact tracks
individually to determine if I will be allowed to compete and to indicate to track officials my age and restricted license status. - I FURTHER UNDERSTAND THAT IF I AM UNDER THE AGE OF 16 THAT I MUST PUR-
CHASE A RESTRICTED LICENSE IN ADVANCE THROUGH THE WISSOTA OFFICE. A RESTRICTED LICENSE WILL NOT BE ISSUED AT A TRACK LEVEL UNDER ANY CIRCUMSTANCES. If I am under 17
years of age, I have included a certified birth certificate.
     14. I understand that if I place in the top 10 in the final WISSOTA national points in 2011, or the top 15 of the Late Model Challenge Series, I must attend the national awards banquet at the Kelly Inn in St. Cloud, MN in
November 2011. I further understand that the WISSOTA Promoters have 10 days after every sanctioned race event to submit to the WISSOTA Promoters Association’s corporate office all points earned by drivers at the sanctioned racing
event. I understand that should said promoter fail to upload any points to WISSOTA via Speednet by midnight October 10, 2011, all points earned by drivers at the Promoter’s sanctioned racing events, that any points that I have earned
will be lost and forfeited. I understand that it is my obligation to verify that WISSOTA Promoters have in fact submitted to the WISSOTA Promoters Association corporate office all points drivers have earned from sanctioned events. If
I do not attend the national awards banquet, I understand that my national point fund or Challenge Series check will be reduced by 25 percent.

COMPETITOR’S SIGNATURE___________________________________________________DATE                                                                                                                   ____________________
          If driver is under 17 years of age, a certified copy of the driver’s birth certificate must be sent along with this license application. If it is not sent, the license will not be processed.

PARENT/GUARDIAN SIGNATURE If Driver Is Under 18 Years Old                                                   ________________________________________________________________________________

EMERGENCY NAME & PHONE________________________________________ (_______) ________________
                                           2011 LICENSING FEES
The listing below reflects the official order of WISSOTA divisions. If you are applying for rookie status in any division (by checking the blank on
the front of this license form), then you are stating that you have not raced more than five (5) shows in that division, or any higher division,
within WISSOTA or at any other track or in any other sanction, in any previous year. If it is later discovered that you did not meet this qualifica-
tion, your rookie status for any potential awards will be denied.

Drivers: Please be sure that entire form is completely filled out and readable before submitting to your track or to WISSOTA for license
approval. If form is not complete, not readable, or if incorrect payment is received, the form will be returned to you for correction; your licensing
to race will be delayed, as will your subscription to All The Dirt!. Do NOT wait to buy your license at the track - order early by mail!

Thank you and best of luck in the 2011 racing season.
                                                                                                                                   The WISSOTA Board of Directors

 q   2011        WISSOTA            LATE MODEL FEE - $110.00
 q   2011        WISSOTA            MODIFIED FEE - $90.00
                                                                                                                                         Order Your
 q   2011        WISSOTA            SUPER STOCK FEE - $80.00                                                                              WISSOTA
 q   2011        WISSOTA            MIDWEST MODIFIED FEE - $70.00                                                                         License
 q   2011        WISSOTA            STREET STOCK FEE - $70.00                                                                             By Mail!
 q   2011        WISSOTA            MOD FOUR FEE - $70.00


            DO NOT WAIT UNTIL RACE NIGHT TO PURCHASE YOUR LICENSE AT THE TRACK.
            ORDER YOUR LICENSE BY MAIL BY FEBRUARY 15, 2011 FOR FASTEST SERVICE!

         TEMPORARY LICENSES: $50 Each, Valid For 1 (One) Event Only.
There will be no “upgrades” allowed from a temporary license to a full license. Please purchase the appropriate license.
                  If paying by check, make it payable to WISSOTA. If paying by credit card, fill out the form below.
                   Mail To: WISSOTA Auto Racing, P.O. Box 297, Dassel, MN 55325

                                PURCHASE LICENSE BY CREDIT CARD
        Driver To Be Licensed: ________________________________________________________

        Name On Credit Card: ________________________________________________________

        Check One: ______Visa • ______ Mastercard • Amount To Charge                                                       (See Above)    ____________

        Address Where Credit Card Statements Are Mailed: ________________________________
        ____________________________________________________________________________

        Account Numbers: ______________ ______________ ______________ ______________

        Expiration Date: (Month/Year) _____/______                           3-Digit Security Code: (On Back Of Card) _______


        Cardholder’s Signature             (Required):___________________________                                         Today’s Date: __________

                                                                                  S P E E D W A Y IN TE R N A T IO N AL




                                                                                 R A C IN G MET H A N O L

				
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Description: Driver License Copy Template document sample