LIC NO.                                                                                          

2011 LICENSE APPLICATION

SOUTH ARCADE SPEEDWAY

NO CHARGE FOR 2011

IN CONSIDERATION OF THE ACCEPTANCE BY CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS, FOR ITíS APPLICATION, ISSUANCE OF LICENSE, MY BEING PERMITTED ON THE SPEEDWAY PREMISES OF CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS SANCTIONED EVENT, OR ANY OF THE FOREGOING, I, FOR MYSELF, MY HEIRS, NEXT OF KIN, PERSONAL REPRESENTATIVES AND ASSIGNS, FOREVER RELEASE AND FOREVER DISCHARGE AND AGREE TO HOLD HARMLESS AND INDEMNIFY CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS, THE PROMOTERS PRESENDING EVENTS ARE PRESENTED, THE PARTICIPANTS THEREON, AND THE OWNERS AND OR SPONSORS AND MANUFACTURERS OF ALL RACING EQUIPMENT USED IN CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS SANCTIONED EVENTS, THE OFFICERS, DIRECTORS, AGENTS, EMPLOYEES AND SERVANTS OF ALL OF THEM INCLUDING CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS INCLUDING NEGLIGENCE OF ANY OF THE FOREGOING THAT MAY ACCRUE TO ME OR MY HEIRS, NEXT OF KIN AND PERSONAL REPRESENTATIVE, FROM EVERY AND ANY LOSS, DAMAGE AND INJURY (INCLUDING DEATH) THAT MAY BE SUSTAINED BY MY PERSON AND PROPERTY WHILE IN, ABOUT AND ENROUTE INTO AND OUT OF PREMISES WHERE CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS SANCTIONED EVENTS ARE PRESENTED.

I HEREBY CERTIFY THAT ANY LICENSE GRANTED HEREUNDER IS GRANTED FOR THE SOLE PURPOSE OF ENABLING ME TO PARTICIPATE IN THE FURTHERANCE OF AN ENTERPRISE, A RACE, OR OTHER MOTORSPORTS RELATED ACTIVITY.  MY PRESENCE IN, ABOUT OR ENROUTE INTO OR OUT OF ANY PREMISIES WHERE CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS SANCTIONED EVENTS ARE PRESENTED IS IN FURTHERANCE OF THAT EVENT.  BY MY SIGNATURE BELOW, I HEREBY FOREVER RELEASE AND ASSIGN TO THE VEHICLE DESCRIBED BELOW, WHETHER PORTRAYED IN STILL OR MOTION PICTURES, DRAWINGS OR OTHER ARTISTIC RENDERSING, RELATED TO OR DEPICTING MY PARTICIPATION IN CHURCHVILLE BUSINESS PARK INC, D.B.A. SAS SANCTIONED EVENTS.

MUST HAVE LICENSE IN ORDER TO GET POINTS AND AWARD MONEY.  POINTS WILL START WHEN LICENSE FORM IS SUBMITTED

PLEASE PRINT

CAR NO.                                                                                                                               DOB                                                                                      

 

LAST NAME                                                                                         FIRST NAME                                                                                     

 

ADDRESS                                                                                                                                                                                                                            

 

                                                                                                                                                                                                                                               

 

HOME PHONE                                                      CELL                                                                      WORK                                                 

 

SOCIAL SECURITY NUMBER                                                                              E-MAIL                                                                            

(MUST HAVE IF DRIVER)

 

DIVISION                             LATE MODEL                   E-MOD               SPRINT              STREET         PURE STOCK           MINI      (CIRCLE ONE)     

                                                                                                                                                                                                                                               

 

IF APPLICANT IS DRIVER AND PAYOUT MONEY GOES TO OWNER OF CAR, PLEASE FILL IN OWNERS INFORMATION.  IF ALL INFORMATION IS NOT COMPLETE, THE 1099 WILL BE FILED UNDER THE DRIVERS NAME.

 

OWNERS NAME                                                                                                                                                                                                                

 

ADDRESS                                                                                                                                                                                                                            

 

PHONE                                                    SOC SEC NO.                                                       OR FED ID #                                                       

                                                                                                                                                                                                                                               

SIGNATURE:

                                                                                                                                                                DATE:                                                                   

 

2011 LICENSE FEE $00.00

 NO FEE FOR 2011

MAKE CHECK PAYABLE TO SOUTH ARCADE AND MAIL TO 369 ATTRIDGE RD   CHURCHVILLE, NY 14428

                                                                                                                                                                                   

 

CHECK #                      CASH                          RECíD BY                              DATE                         

DATE LICENSE CARD MAILED                                         

 

**CAR MUST BE REGISTERED**

SEE CAR REGISTRATION FORM