River Valley Chamber of Commerce
TSD Fun & Wonder
Rumford, Maine
August 1,1999

ENTRY FORM

DRIVER

Name:________________________________

Address:______________________________

City, State,ZIP:________________________

Phone:_______________________________

Minor (under 19 years of age)?____Yes___No
NAVIGATOR

Name:_______________________________

Address:______________________________

City, State, ZIP:________________________

Phone:________________________________

Minor (under 19 years of age)?___Yes___No

VEHICLE

Vehicle Make & Model______________________________________________Year_______

Color_________________________License Plate__________________________State_____

Insurance Co._____________________Policy#____________________Expires___________

Does either contestant own this vehicle?____Yes_____No

If NO, indicate the name and address of the owner__________________________________

CLASS ____A____B____C____JEEP____NOVICE (less than 5 rallys)

ENTRY FEES: (See flyer for entry fees) Amount enclosed: $___________

The Entrant warrents that an Auto Insurance policy with liability limits of not less than
$25,000/$50,000/$25,000 is in force for each vehicle entered. In signing this form I agree to abide by
all the regulations and decisions of the Rally Committee (If either the Driver or the Navigator is under
18, a minor release form must be obtained and filled out before the rally.)

____________________________
Signature of Driver
____________________________
Signature of Navigator
Please make ckecks payable to:
River Valley Chamber of Commerce

Send this form to:
Atlantic Rallies
P.O. Box 16
Mechanic Falls, ME 04256

ADMINISTRATIVE USE ONLY

Car # assigned____________