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Rally in the Valley For Cars ( Vans, SUVs, Pickups ) Preregistration Form Mail by August 16, 2003 1st Annual Rally in the Valley to be held on Saturday August 23, 2003 in Bradford, PA. Registration opens at 11:00 AM at the Congress Street Zippo parking lot. Mail to: Dennis Roesch, 24 Dennis Lane, Bradford, PA. 16701 by August 16, 2003. Participant Information Driver Name: __________________ Navigator Name: _____________________ Address: ______________________ Address:____________________________ City, State, Zip: ________________ City, State, Zip: ______________________ SCCA Member No_Yes_ Region _____ SCCA Member No_Yes_ Region ______ Are you a Minor? Yes__ Age___ No__ Are you a Minor? Yes__ Age____ No___ Vehicle Make: _______________ Model: ______________ Color: ___________ Year: _______ License Plate (Tag) Number: _____________ State: _________ Does the Driver or Navigator own this Vehicle? Yes __ No __ If no complete the following: Name and Address of the owner: __________________________________ __________________________________ __________________________________ Entry Information Participation Fee: $20.00 per vehicle Class: Novice: ______ Tourist ( More than 2 people in vehicle ): ______ Rallyist ( Experienced ) ____ The entrant warrants that an auto insurance policy with liability limits of $100,000 / $200,000 / $50,000 is in force for each vehicle entered. We certify this entry is in compliance with Road Rally regulations. Article G 10 ( Car Registration ) and Article G 11 ( Classes ). Driver: ________________________ Navigator: _____________________ Date: __________ Date: ___________ Questions: Please call Dennis Roesch @ 814-368-5427, If no answer please leave a message and I will return your call or email me at email@example.com.
"Rally in the Valley"