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Pure
Stocks $1,000 to Win on Friday, October 30th.
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FIVE MILE POINT
OFFICIAL ENTRY FORM
Friday, October 30th – 7 p.m.
– Fall Southern Tier Showdown.
Driver Name: ___________________________________________ Car #: _____________
(car numbers
will not be assigned until fmp office receives
receipt of paid entry application)
Applicant Address: _____________________________________________________________
(please
print and fill out completely)
__________________________Zip
Code: ______________ S.S #: _______-______-______
Racing Division: ______________________________
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) ___________________
CAR OWNER INFORMATION MUST BE
COMPLETELY FILLED OUT PRIOR TO BEING PAID PURSE!
Please be sure to fill out every
part of this form. It is important to
have a complete mailing address – email address and phone number in event
of rain, delays or other information that could benefit your race team.
Early Entry Fee Must Be Received
Prior to October 30th - $5 added
after early entry date
Entry fee does not
include driver
admission for this event.
PLEASE CIRCLE CLASS…
Mail To:
Five Mile Point Speedway
Pure
Stock………………………..$10 P.O. Box 54 Kirkwood, NY 13795
please make checks payable to:
Five Mile Point
For Information Call the
Five Mile Point
IN CONSIDERATION of the acceptance by Five
Mile Point Speedway Motorsports
(Southern Tier Micro Reality Racing, Inc.) of the 2009 Entry Blank, my
being permitted on the Five Mile Point Speedway premises for any event, or any
of the foregoing, I for myself, my heirs, next of kin, personal representatives
and assigns, FOREVER RELEASE, REMISE and FOREVER DISHCAHRGE and AGREE TO HOLD
HARMLESS and INDEMNIFY FIVE MILE POINT SPEEDWAY MOTORSPORTS, INC. THE PROMOTERS
PRESENTING EVENTS or the owners (lessors) of the
premises on which Five Mile Point Speedway events are presented, the
participants theron, and the owners, sponsors and
manufacturers of all racing equipment used in Five Mile Point Speedway events,
the officers, directors, agents employees and servants of all of them,
including Five Mile Point Speedway officials and Five Mile Point Speedway
license members, 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 , about and enroute
in to and out of Five Mile Point
Speedway premises. ABSOLUTELY NO REFUNDS!
Driver
Print Name:
_______________________________________________________
Driver Signature:
_____________________________ Date Signed: _______________