HOLLYWOODMOTORSPORTS DRIVER ENTRY FORM

Name________________________________ NICKNAME_______________

Address: _______________________________________Home Ph_________________

City ___________________ST __________Zip__________Cell Ph__________________

Class___________Car #___________

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______

SEPT 5TH LABOR DAY 1PM START

ROSHALT, OFFICIAL PORTAGE COUNTY FAIR CHECK YOUR CLASS YOU ARE ENTRYING

ALL CLASSES ARE THE SAME AMOUNT $40 PRE ENTRY $60 THE DAY OF

OPEN CLASS__________ COMPACTS________ MIDSIZE_______ MULTIPAL MINIES______

HOLLYWOOD MOTORSPORTS 2777 WESTMOOR RD OSHKOSH WI. 54904

CHARITY DERBY SET 17TH 12:30 START

TEAM DERBY______________$300

OPEN CLASS CLEAN UP HEAT___________$50

MULTIPAL MINIS______________$50

MIDSIZE____________$50

TRUCKS________________$50

MAKE CHECKS OUT TO ELDORADO LIONS CLUB AND SEND TO CRASHING FOR A CAUSE

W9261 COUNTY N ELDORADO WI. 54932**DO NOT MAKE MONEY ORDERS OUT TO JOE KOPF OR HOLLYWOOD.