The Great Race » 2012 Registration

2012 Registration

SECTION 1: ENTRANT IDENTIFICATION

(Routine Correspondence goes to the Entrant.)

Your First Name (required)

Your Last Name (required)

Your Middle Initial

Spouse First Name (required)

Mailing Address (required)

City, State, ZIP (required)

Your Office Phone

Your Home Phone (required)

Your Cell Phone (required)

Your Birthday (required)

Your Drivers License # (required)

Your License State (required)

Your License Expiration (required)

Your Hometown (required)

Please Select Your T-Shirt Size

Emergency Contact Name(required)

Emergency Contact Phone Number(required)

Emergency Contact E-Mail(required)

Website

Your Email (required)

Team Name

My Entry Will Be

SECTION 2: DESCRIPTION OF VEHICLE

Year

Make

Model

Color

VIN

Engine - Horsepower/Displacement/Type

Transmission (3-speed, 4-speed, other)

Overdrive - Type/Make

Original Body?

Body Manufacturer (if other than original)

Performance (0 to 50 MPH)

Top Speed (MPH)

Competition History of Vehicle

Rally Experience: Driver

Rally Experience:Navigator

License Plate Number

State

Expiration

Vehicle Insurance Company

Policy Number

Policy Expiration

Coverage Limits

(Certificate of Liability Insurance from Insurance Company on race and support vehicles required by May 15, 2012.)

Car # Desired: 1st Choice

2nd Choice

3rd Choice

Vehicle Condition

Any Modifications

(if yes, please explain below.)

Vehicle Modifications

Is Vehicle authentic in every detail?

(if no, please explain below.)

How does Vehicle differ from being authentic?

(This information determines age factor refer to V.D of Event Regulations. This section of data goes to the Event Technical Director for Technical Inspection purposes.)

SECTION 3: OWNER IDENTIFICATION

Last Name(required)

First Name(required)

Company Name (If Applicable)

Mailing Address(required)

City, State, ZIP(required)

Your Office Phone(required)

Your Home Phone (required)

Your Cell Phone (required)

By clicking here, Owner warrants ownership of and insurance on the Vehicle described in Section 2, and gives permission for use and entry of this vehicle in the Great Race 2012: Yes

SECTION 4: COMPETITION DIVISION/AWARD ELIGIBILITY

(please refer to Event Regulations I.E.)

In which Division will you compete? (See Event Regulation I.E.)

Are you also eligible for Rookie Class? (See Event Regulation I.F.)

SECTION 5: DRIVER IDENTIFICATION

First Name (required)

Last Name (required)

Middle Initial

Spouse First Name (required)

Mailing Address (required)

City, State, ZIP (required)

Office Phone

Home Phone (required)

Cell Phone (required)

Birthday (required)

Drivers License # (required)

License State (required)

License Expiration (required)

Hometown (required)

Please Select T-Shirt Size

Emergency Contact Name(required)

Emergency Contact Phone Number(required)

Emergency Contact E-Mail(required)

Email (required)

(Please note: if you have an Alternate Driver, please provide the above information on a separate sheet when you mail completed application package to us.)

SECTION 6: NAVIGATOR IDENTIFICATION

First Name (required)

Last Name (required)

Middle Initial

Spouse First Name (required)

Mailing Address (required)

City, State, ZIP (required)

Office Phone

Home Phone (required)

Cell Phone (required)

Birthday (required)

Drivers License # (required)

License State (required)

License Expiration (required)

Hometown (required)

Please Select T-Shirt Size

Emergency Contact Name(required)

Emergency Contact Phone Number(required)

Emergency Contact E-Mail(required)

Email (required)

SECTION 7: SUPPORT CREW IDENTIFICATION

(Please provide if you have it -although this can be provided at a later date.)

Crew Member #1

First Name

Last Name

Middle Initial

Spouse First Name

Mailing Address

City, State, ZIP

Office Phone

Home Phone

Cell Phone

Drivers License #

License State

License Expiration

Hometown

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact E-Mail

Crew Member #2

First Name

Last Name

Middle Initial

Spouse First Name

Mailing Address

City, State, ZIP

Office Phone

Home Phone

Cell Phone

Drivers License #

License State

License Expiration

Hometown

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact E-Mail

SECTION 8: SUPPORT VEHICLE

Please read Section II.E. of the Event Regulations. Each contestant vehicle entered may have one official support vehicle at no charge. If you share support with another team, or have additional vehicles, please indicate below. (Private and X-Cup Entry Support Vehicles should not exceed 45' total length, see section II.E.1.b of the Event Regulations.)

This Vehicle WILL NOT have a Support Vehicle

This Vehicle WILL have Support Vehicles

Will Share Support with Car #

SECTION 9: RECIPIENT OF PRIZE MONEY

Individual or Company Name

Mailing Address

City

State

ZIP

Federal Business Tad ID Number (or SSN for Individual)

(Great Race will issue a 1099 to party receiving the check.)

Telephone Number

SECTION 10: SPONSOR IDENTIFICATION

(For Business/Corporate Sponsored Entries only.)

Sponsor Name

Name Of Contact

E-Mail Address

Address

City, State, ZIP

Office Phone

Fax Number

Type Business/Product/Service

No. Years in Business

SECTION 11: TERMS AND CONDITIONS OF ENTRY

1. The entry fee, as stated herein, is for one vehicle entered in the 2012 Great Race (the “Event”).

2. Owner/Entrant understands that this entry is a conditional offer to participate and if accepted, constitutes an agreement with The Great Race to take part in the Hemmings Motor News 2012 Great Race (hereinafter “Great Race”), unless otherwise prevented by circumstances beyond the control of Owner/Entrant. 3. The undersigned agrees for himself/herself and his/her team to comply with all federal, state and local laws related in any way to the Event.

4. The undersigned certifies that to the best of his/her knowledge all information on this form is true and correct, and that licenses and insurance policies listed above are and will be legally valid and in force throughout the duration of the Event and further that he/she has the authority to provide such information to the Great Race.

5. The undersigned further acknowledges that All Participating Crew and Support members must sign an insurance waiver and indemnity agreement in order to participate in the Event.

6. The undersigned agrees that all hotel reservations are to be made through Covington Travel using their online registration site.

7. The undersigned further acknowledges receipt of the Great Race Event Regulations and acknowledges and represents that he/she has (a) thoroughly read the Event Regulations; (b) understands the Event Regulations including without limitation the rules and regulations pertaining to prizes; and, (c) agrees to comply with all such regulations as well as any and all supplemental regulations that may be subsequently issued by the Great Race.

8. Finally, the undersigned acknowledges that All Participating Crew and Support members must agree to permit Great Race, the promoter of the Event, and their assigns, the use of their name, voice and/or likeness and photographic/ videographic images of them and their vehicle for news, publicity and feature use, films and video, newspapers, magazines and all other media in connection with advertising and for purposes of trade.

By checking this box, you agree to the terms and conditions stated above.

Grand Start

2012 Registration

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