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Name:________________________________ Address:______________________________ City, State, ZIP:________________________ Phone:_______________________________ Minor (under 19 years of age)?____Yes___No |
Name:_______________________________ Address:______________________________ City, State, ZIP:________________________ Phone:________________________________ Minor (under 19 years of age)?___Yes___No |
Vehicle Make & Model______________________________________________Year_______
Color_________________________License Plate__________________________State_____
Insurance Co._____________________Policy#____________________Expires___________
Does either contestant own this vehicle?____Yes_____No
If NO, indicate thee name and address of the owner__________________________________
____A____B____C____JEEP____NOVICE (less than 5 rallys)
(See Flyer for entry fees)
Amount enclosed: $___________
Car # assigned:____________
CLASS
ENTRY FEES
Signature of Driver
Signature of Navigator
(with payment) to:
Registrar
P.O. Box 16
Mechanic Falls, ME 04256