Lawton Speedway

2010 Registration Date: ___________________ Registration Fee: $20

Champ Sprints USA Modifieds Limited Modifieds       Factory Stocks             Mini Stocks

Car #:_____________

Driver: ______________________________________________Birthdate:____________________________

Social Security No.:_____________________________ (must have this number)

Address: _________________________________City:____________________State:_____Zip:____________

Home Phone :(____) ____________________________ Cell Phone :(_____) ______________________

E-Mail Address: __________________________________________

1099 Tax Form: ______Driver ______Owner

(Fill out Owner information if Owner is Different than Driver AND Owner Receives the 1099 Tax Form)

Owner: _______________________________________ Social Security No.__________________________

Address: _________________________________City:___________________State:_____Zip:_____________

Home Phone :(____) ______________________________ Cell Phone :(____) ______________________

E-Mail Address: _________________________________________

Tax Certification

We certify that we have supplied a valid Social Security/Taxpayer Identification Number for the purpose of issuance of Form 1099. Driver will receive 1099 unless specifically marked otherwise.

Publicity Release

I hereby authorize Lawton Speedway to use any pictures, descriptions or accounts of any activities at any event at the speedway for press releases, publicity or other similar purposes. I also request to be placed on the speedway mailing list.

Rules Acknowledgment

I have read a copy of the Lawton Speedway 2009 rules and agree to comply with all speedway rules listed there in.

___________________________________________ __________________________________________

Driver Signature Owner Signature

Mail Registration Form and Fee To: Lawton Speedway, PO Box 582, Cache, OK 73527