DERBY ICONS DRIVER ENTRY FORM

Name________________________________Screename/Nickname ____________

Address: _______________________________________Home Ph______________

City ___________________ST __________Zip__________Cell Ph_______________

Class_________ Event___________Car #______ Color___________(No Black cars)

Car year/make/model _________________________________________________

Sponsors ____________________________________________________________

Birthdate ____________________________

Email Address ________________________________________________

DRIVER AGREEMENT:

My signature below confirms that I have read all rules and regulations & agree to abide by such. I understand that by participating in this event that I also agree to comply with the requirements set forth for this show. In addition, I agree to exercising good sportsmanship at all times during the event. I fully understand that if I am unable to participate for any reason that my entry fee is forfeited. I understand there are no refunds. I understand I am not able to sell or give away my entry, or otherwise make driver changes without first contacting this promoter. I understand if I am disqualified for any reason, I will not receive any refunds (including pit passes). This includes not passing inspections, if I am unwilling or unable to make the required changes .I understand that if I place and receive prize money that my social security number will be requested and I agree to provide given the circumstances. My signature below confirms that I understand and agree to these terms set forth.

Drivers Signature_________________________________________________Date______

Comments/Opinions/Suggestions: ( Classes, Payouts, Entry Fees, Attractions, Promotions, etc. )

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Make checks payable to: Derby Icons

W930 Eau Claire Rd

Genoa City WI 53128

262-295-8061

Derby Icons Promotions - www.derbyicons.com