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MODIFIED ROC 100 FINALE –
MIN. $5,555 TO WIN!. |
2010 Race of Champions Dart
Dirt Modified Tour Entry Sheet
RoC 100 Finale: Five Mile Point
Applicant Name: ___________________________________________ Car #: _____________
(car numbers will not be assigned until roc office receives
receipt of paid entry application)
Applicant Address: _____________________________________________________________
(please
print and fill out completely)
__________________________Zip Code:
______________
S.S #: _______-______-______
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 competing in one or all events must file a tour entry sheet prior
to each race.
Early Entry Fee: $15 _________ (must be received prior to Oct. 25,
2010)
Late Entry Fee: $20 _________ (received after Oct. 25, 2010)
IN CONSIDERATION of the acceptance of this Race of Champions Modified
Tour Entry 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 Race of Champions Modified Tour participants, 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 Race of Champions Modified Tour
event.
By Signing this 2010 Race of Champions Modified Tour membership Form I
acknowledge that I have read the entire form and understand its contents. The Race of Champions Modified Tour has
consent to use driver name and likeness for promotional and souvenir materials. This Race of Champions entry may be revoked
at any time for failure to adhere to tour rules, implied or assessed. Entry must be filed at each event in order to
compete.
Applicant
Signature: _____________________________
Date Signed: _______________
Checks may be made payable to:
Race of Champions,