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NAME:______________________________________________________________________

ADDRESS:___________________________________________________________________

CITY:______________________________________STATE:__________ZIP CODE:_________

PHONE: DAY (_______)_____________________NIGHT (_______)_____________________

DRIVERS LICENSE#:_______________________________________________STATE:______________
(TO BE CONFIRMED DAY OF THE EVENT)
CLUB AFFILIATION:_____________________________________________STATE:______________
(NO AFFILIATION IS REQUIRED)
LIST ANY AUTOCROSS OR TRACK EXPERIENCE:____________________________________

_____________________________________________________________________________

_____________________________________________________________________________
(NO EXPERIENCE NECESSARY)
HAVE YOU EVER RUN THE NORTH COURSE AT POCONO?: (check one) YES:_____ NO:_____

IF YES, WHAT LAP TIMES DO YOU EXPECT TO TURN?_______________________________

VEHICLE INFORMATION

YEAR:________ MAKE:____________________ MODEL:_____________________________

BODY STYLE:__________________

SUSPENSION: STOCK_____ MODIFIED_____

ENGINE H.P.:__________________ STOCK_____ MODIFIED_____

PAYMENT INFORMATION

EARLY TRACK REGISTRATION ---------- ON OR BEFORE AUGUST 1ST:  $135.00
LATE TRACK REGISTRATION ----------------------- AFTER AUGUST 1ST:  $160.00
SEND CHECKS OR MONEY ORDERS, MADE PAYABLE TO:
BAYSHORE CORVAIR ASSOCIATION, INC.
21 ARDMORE ROAD
FREEHOLD, NEW JERSEY, 07728
(FOR CLUB USE ONLY)

DATE RECV’D:_____________ CHECK#:___________ AMOUNT:____________

BANK NAME & ADDRESS:_________________________________________________

REGISTRATION PACKAGE SENT:_____________

CAR NUMBER:___________ CAR CLASS:_______________ GROUP:_____________