Kankakee County Speedway

213 W 4000 S / Kankakee, IL 60914 / (815) 935-9000

2010 DRIVERS REGISTRATION FORM

UMP LATE MODEL / UMP MODIFIED / UMP STOCK CAR / I-MOD / HORNET     

CLASS (CIRCLE ONE): LM  MO  SC  IM  HO    CAR # ____________

 

Driver’s Name: ________________________________________________________________________

 

Street Address: ________________________________________________________________________

 

City: ____________________________ State: ___________________ Zip Code: __________________

 

E-Mail Address: _______________________________________________________________________

 

Home Phone: (_______) ______________________ Work Phone: (________) ____________________

 

Are you at least 16 years old? Yes or No           2010 ROY Candidate? Yes or No

 

SOCIAL SECURITY OR TAX I.D. NUMBER OF PERSON OR ENTITY TO RECEIVE 1099 INFORMATION

 

Name or Entity: _______________________________________________________________________

 

Address: _____________________________________________________________________________

 

City: ______________________________ State: __________________ Zip Code: _________________

 

Phone: (________) __________________ SSN or Tax I.D. No.: _________________________________

 

Signature: ____________________________________________ (Title if Corp) ___________________

DRIVER / CAR INFORMATION

 

Vehicle Make: ________________ Yr.: _________ Model: __________________ Color: ______________

 

Sponsors: _____________________________________________________________________________

 

Years Racing: ________________ Championships: ____________________________________________

OPTIONAL INFORMATION

 

Occupation: ___________________________________________________________________________

 

Hobbies: ______________________________________________________________________________

 

Married: Yes or No Spouse’s Name: __________________________________________

DISCLAIMER: I understand that my signature here along with the proper registration fee makes me a member of the Kankakee County

Speedway. I agree to abide by the racing rule book of Kankakee County Speedway and it’s interpretation by officials. I hereby give my

permission to use photographs of myself and/or race car as part of their racing publicity promotions. I agree not to hold Kankakee County

Speedway responsible for disqualification or damage to either car or driver and I agree that I consider the track is in safe racing

condition when I take part in any racing activity.

 

SIGNATURE: _________________________________________________ DATE: _________________

 

NOTE: ANY PAYOFF NOT PICKED UP ON RACE NIGHT  CAN BE PICKED UP AT THE NEXT RACE!