2012 Five Mile Point Speedway Membership
Application
Please Check One: Driver Membership _____ Crew Membership _____
Applicant Name: ___________________________________________ Car #: _____________
(car
numbers will not be assigned until fmp office
receives receipt of paid membership application)
Applicant
Address:
_____________________________________________________________
(please
print and fill out completely)
__________________________Zip Code:
______________
S.S #: _______-______-______
Racing Division: Mod ____ SM ___
IMCA ___PS ___Figure 8___Cats: novice___ expert____
Birth Date: ____/____/____ Phone Numbers: (h) __________________ (w) _________________
Cell Phone Number: ___________________ Email Address: __________________________
Driver Website: ______________________ Other Car #
Choices: _____________________
Car Owner:
____________________________ S.S #:
_______ - _______ - _______
Owner Address:
_____________________________________________ Zip Code: __________
Phone Numbers: (h) ____________________ (w) __________________ (c)
___________________
THE PERSON THAT ANY PURSE OR POINT FUND
MONIES ARE PAID TO SHOULD BE LISTED
ABOVE
AS CAR OWNER WITH COMPLETE INFORMATION PROVIDED.
Every driver wanting to be eligible for
point fund awards, contingency or bonus awards must file a membership
award. This includes any or all bonus
lap money, giveaways or promotional incentives.
The Five Mile Point Speedway Membership Card will be sent to each individual
and will provide the lowest discounted pit admission price at each event when
offered. Anyone entering the pit area is
considered a “participant” with a race team but may only receive the posted
discounted pit price with a fmp
membership card.
Cost $50
prior to March 21, 2012 cost after
March 21, 2012 is $60
IN CONSIDERATION of the acceptance of this Five Mile Point
Speedway Membership Form, I for myself, my heirs, next of kin, personal
representatives and assigns, FOREVER RELEASE, REMISE and FOREVER DISCHARGE and
AGREE TO HOLD HARMLESS and INDEMNIFY the promoters presenting races or other
events, the owners (lessors) of the premises at which
these events are held, the participants, theron, and
the owners, sponsors and manufacturers of all racing equipment used in any of
these events, the officers, directors, agents, employees and servants of all of
them, including officials and Five Mile Point Speedway members, Southern Tier Micro Reality Racing,
Inc. (STMRR, Inc.), Five Mile Point Speedway, Inc. of and from all liability,
claims, action and of possible causes of action whatsoever. Including negligence of any of the
foregoing, that may accrue to me or my heirs, next of kin and personal
representatives from every and any loss, damage and injury, including death,
that may be sustained by my person and property while in or about and enroute into and out of any Five Mile Point Speedway event.
By signing this 2012 Five Mile Point
Speedway membership Form I acknowledge that I have read the entire form and
understand its contents. Five Mile Point
Speedway has consent to use driver name and likeness for promotional and
souvenir materials. This Five Mile Point
Speedway Membership may be revoked at any time for failure to adhere to tour
rules, implied or assessed. Everyone
entering the pit area must be a full member or temp. (single
event member).
Applicant
Signature: _____________________________
Date Signed: _______________
Checks may be made payable to: Five Mile Point Speedway,