PAID:__________SHIRT SIZE:______ Team Points Check Yes______ No______

cash/check

IF YOUR ADDRESS CHANGES DURING THE YEAR, PLEASE NOTIFY THE OFFICE. (PLEASE PRINT)

NAME: ________________________________ DATE: _______________________

ADDRESS: _____________________________ CITY ________________________

STATE______________ ZIP______________ FAX #: (____)________________

EMAIL:______________________EMERGENCY CONTACT (_____)_______________

HOME PHONE #: Area code (______)________________

IF HIGH SCHOOL NEED AGE:____________

WORK PHONE #: ____________ (OPTIONAL) CELL PHONE #: _______ (OPTIONAL)

CLASS: ___________________________________ CAR #: ___________________________________

YEAR/MAKE/MODEL/COLOR OF CAR OR MX:

_______________________________________________________________________

(NEED THIS FOR PICTURES)

*NOTE: IF YOU ARE A MOTORCYCLE, YOU MUST COLLECT POINTS WITH MX AND NOT WITH CARS.

IN 2004 ALL MOTORCYCLES WILL RUN AGAINST MOTORCYCLES ONLY.

NHRA MEMBERSHIP #: ______________ EXPIRATION DATE: ____________________

NHRA LICENSE (CAR) #:____________ EXPIRATION DATE: ____________________

HIGH SCHOOL REPRESENTED (IF APPLICABLE) _____________________________________________