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2013 USAC Application
for
Membership |
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| * PLEASE FILL
OUT THE FORM COMPLETELY |
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| First Name: ______________________________________________________________________________________________________ |
| Last Name: ______________________________________________________________________________________________________ |
| Address: ________________________________________________________________________________________________________ |
| City: _____________________________________________________
State: _________________________________ Zip: _____________ |
| Date of Birth: ______________ Email: __________________________________________________________________________________ |
| Online Password Request: ____________________________________________________________________________________________ |
| Home Phone: ______________________________________________
Cell Phone: ______________________________________________ |
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| Insurance
Beneficary (Someone other than yourself) |
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| First Name: _______________________________________________________________________________________________________ |
| Last Name: _______________________________________________________________________________________________________ |
| Phone: ___________________________________________________________________________________________________________ |
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Please Select License
Type(s) on Page 2 |
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All Car Entrants
must fill out page 3 |
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All Applicants must
agree to policies on pages 4-6 |
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All Applicants must
complete page 7 |
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| Series |
License Type |
Cost |
Requested (Please check all
that apply) |
| Super
License |
Driver |
$900.00 |
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| Silver
Crown |
Driver |
$500.00 |
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Entrant |
$500.00 |
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Driver/Entrant |
$800.00 |
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Driver Dirt Only |
$250.00 |
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Driver Pavement Only |
$250.00 |
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Crew |
$150.00 |
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| National
Sprint |
Driver |
$350.00 |
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Entrant |
$350.00 |
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Driver/Entrant |
$500.00 |
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Crew |
$150.00 |
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| ALL
Western Sprint Divisions |
Driver |
$250.00 |
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| Including:
CRA, Western Classic |
Entrant |
$250.00 |
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| WC360,
Western Sprint |
Driver/Entrant |
$400.00 |
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| Southwest
Sprint |
Crew |
$150.00 |
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| National
Midget |
Driver |
$350.00 |
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Entrant |
$350.00 |
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Driver/Entrant |
$500.00 |
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Crew |
$150.00 |
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| DMA
Midget |
Driver |
$250.00 |
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Entrant |
$250.00 |
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Driver/Entrant |
$400.00 |
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Crew |
$150.00 |
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| Western
Midget |
Driver |
$250.00 |
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Entrant |
$250.00 |
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Driver/Entrant |
$400.00 |
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Crew |
$150.00 |
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| Ignite
Midget |
Driver |
$250.00 |
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Entrant |
$250.00 |
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Driver/Entrant |
$400.00 |
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Crew |
$150.00 |
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| USA
Membership |
Jeffrey Hougue Realtor.com |
$35.00 |
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Action Track USA |
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| USAC
600 Sprints |
Driver |
$150.00 |
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| Others |
Race Official |
$150.00 |
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Sponsor |
$150.00 |
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Media |
$150.00 |
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Fan Membership |
$150.00 |
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| Must be filled
out for all car entrants |
| Car Entrant
Information: |
| Car 1 |
| Series for Competition: ____________________________________________________________________________________________ |
| Desired 2013 Car Number: _________________________________________________________________________________________ |
| Car Entrant Name (As Listed For Points):
______________________________________________________________________________ |
| Chassis Make___________________________________________________________________________________________________ |
| Engine Make____________________________________________________________________________________________________ |
| Sponsor Name __________________________________________________________________________________________________ |
| PAYEE
INFORMATION: (Must Be Filled
Out To Be Paid) |
| First Name: _____________________________________________________________________________________________________ |
| Last Name: _____________________________________________________________________________________________________ |
| Address: _______________________________________________________________________________________________________ |
| City: ____________________________________________________
State: _______________________________ Zip: ______________ |
| TAX ID or SS#:__________________________________________________________________________________________________ |
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| Other Same Series
Cars To License - Additional Memberships
Fees Will Apply |
| Car 2 |
| Series for Competition: ______________________________________________________________________________________________ |
| Desired 2013 Car Number: ___________________________________________________________________________________________ |
| Car Entrant Name (As Listed For Points):
________________________________________________________________________________ |
| Chassis Make_____________________________________________________________________________________________________ |
| Engine Make______________________________________________________________________________________________________ |
| Sponsor Name ____________________________________________________________________________________________________ |
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| Car 3 |
|
Series for Competition: ______________________________________________________________________________________________
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| Desired 2013 Car Number: ___________________________________________________________________________________________ |
| Car Entrant Name (As Listed For Points):
________________________________________________________________________________ |
| Chassis Make_____________________________________________________________________________________________________ |
| Engine Make_____________________________________________________________________________________________________ |
| Sponsor Name ____________________________________________________________________________________________________ |
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| Please check
all boxes |
| Application
for annual membership and / or license certifications, acknowledgment
& authorization for publicity usage. |
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| APPLICATION.
I hereby apply for a license from the United States Auto Club, Inc.
(USAC) of the type specified on this license. I certify that the information
supplied by me on this license is true and correct and may be relied
upon by USAC. I understand that a license is subject to the Official
Competition Rules of USAC. If my application is approved by USAC I
agree to be bound by such Official Competition Rules and agree that
decisions by USAC and/or interpretation of rules will be governed
exclusively by the administrative review and appeal procedure set
forth in such rules. |
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| CERTIFICATIONS.
I certify that I am 18 years of age or older. (In consideration of
the acceptance by USAC of this application an applicant who has achieved
the age of 18 but has not achieved the age of majority in the state
where the applicant resides, must have a parent or natural guardian
sign this application, authorization, release and waiver of liability.)
I certify that I am not an employee of USAC. I certify that I will
assume all responsibility for all charges, premiums and taxes, if
any, payable on any funds that I may receive as a result of my competitive
activities, including without limitation, social security taxes, unemployment
insurance taxes, compensation insurance, income taxes and withholding
taxes. |
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| ACKNOWLEDGMENT.
I hereby acknowledge and agree that I have no right, property or interest
in any radio or television broadcast, motion pictures, still photographs,
tape, or sound reproductions taken, made, transmitted, reproduced,
or used for any USAC sanctioned event, including practice, qualifications,
the race, awards ceremonies or other event associated with the racing
event, and also including but not limited to pictures and sound of
me alone or with other persons, with or without racing equipment,
as well as any and all receipts there from, and any transcription
thereof. |
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| AUTHORIZATION
FOR PUBLICITY USAGE. I agree that USAC, or its assigns, on
a non-exclusive basis, may use my name and pictures, including pictures
of my racing equipment and pictures taken at any USAC sanctioned event
for publicity purposes, but not for commercial sponsorship of any
product. |
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I
have read and agree to the Authorization for Publicity Usage. |
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| Annual release
and waiver of liability, assumption of risk & indemnity agreement. |
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| In consideration of being granted a license
and in consideration of being permitted to enter for any purpose any
"restricted area" (herein defined as including but not limited
to the racing surface, pit areas, infield, garage areas, and all walkways,
roadways, concession areas and other areas appurtenant to any area
where any activity related to the competitive racing event shall take
place)": |
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| RELEASE AND WAIVER OF LIABILITY: I, for
myself, my heirs, next of kin, personal representatives and assigns,
hereby release, waive, discharge and covenant not to sue the United
States Auto Club, Inc. (USAC), its successors and assigns, the race
organizer presenting USAC sanctioned events, the owners and lessees
of premises on which USAC sanctioned events, including car owners,
drivers, mechanics, pit crews, and any persons in any restricted area,
promoters, sponsors, advertisers, manufacturers of all racing equipment
upon the premises, and the officers, directors, officials, representatives,
agents and employees of all of them (all of whom for the purposes
herein are referred to as "releasees") from all liability,
loss, claims, demands, possible causes of action, court costs, attorneys'
fees and other expenses arising from any lawsuit that may otherwise
accrue from any loss, damage or injury (including death) to my person
or property in any way resulting from, or arising in connection with,
or related to, any sanctioned event, and whether arising while engaged
in competition or in practice or preparation therefore, or while upon,
entering or departing from said premises, from any cause whatsoever
including without limitation, the failure of anyone to enforce rules
and regulations, failure to make inspections, or the negligence of
releasees or other persons. |
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| ASSUMPTION OF RISK. I know the risk to
myself and property, both from known risk and unanticipated risk,
while in or upon the restricted area or while participating or assisting
in a sanctioned event, and I do so willingly, voluntarily and in reliance,
not upon the property, equipment, facilities and existing conditions
furnished by others, but upon my own judgment and ability, and I thereby
assume all risk of loss, damage or injury (including death) to myself
and my property from any cause whatsoever and whether or not attributable
to the negligence of releasees or other persons. |
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| INDEMNITY AGREEMENT. I hereby agree to
indemnify and hold harmless the releasees and each of them from any
loss, liability, damage or cost they may incur due to the presence
of the undersigned in or upon the restricted area, whether caused
by the negligence of releasees or other persons. |
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I
have read and agree to the Annual Release and Waiver of Liability. |
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| Substance Abuse
Policy |
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| Preamble |
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| The United States Auto Club "(USAC)"
strives to maintain the integrity of the Club and its Events (Event
as defined in the USAC Rule Book). USAC is concerned about the problem
of substance abuse in America's society and, more particularly, the
threat that this may create for the safety of our racing participants.
The use of illegal drugs at any time, or the use of alcohol during
an Event, and even the proper use of certain medications during an
Event, may endanger the internal and external perception of the Club.
Such conduct cannot be permitted by USAC. |
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| With the above in mind, this Substance
Abuse Policy ("Policy") has been adopted. It applies to
drivers, mechanics and crew members (hereinafter "Competitor"
or "Competitors"), as well as to USAC officials (hereinafter
"Official" or "Officials"). It may also be applied
to other participants in an Event as USAC deems appropriate in its
sole discretion. |
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| 1. Prohibited
Acts and Substances |
| A. Prohibited
Substances |
| For the purpose of this Policy, "prohibited
substances" are substances that are determined by USAC, in its
sole discretion, to adversely affect the integrity of the Club or
well-being of Competitors or Officials, or others, or the performance
of a Competitor or Official in connection with an Event. "Prohibited
substances" include, but are not limited to, illegal drugs such
as marijuana, cocaine, and hallucinogens. Furthermore, for purposes
of the foregoing, the definition of "prohibited substances"
also includes, without limitation, paraphernalia associated with illegal
drug use and mind-altering and/or addictive substances, which are
not sold as drugs or medicines, but are used or marketed for their
mind or behavior-altering effect. USAC may make a determination that
any particular substance is a prohibited substance at any time, in
its sole discretion. Competitors and Officials are prohibited from
using, possessing, purchasing, selling, manufacturing and/or participating
in the distribution of prohibited substances, regardless of the amount,
at any time. |
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| B. Proper and
Improper Use of Prescription and Over-the-Counter Medications/Substances |
| USAC recognizes that there are many prescription
and over-the-counter medications that serve essential or beneficial
purposes for the health and well-being of Competitors and Officials,
and nothing in this Policy is intended to discourage the proper use
of these medications. Just as importantly, however, it must be recognized
that there are some medications that, even when properly used, may
adversely affect a participant's fitness to be involved in a racing
event or events. For example, many types of cough medicines contain
codeine, which is a potent narcotic that may result in drowsiness
or diminished alertness. |
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| Misuse and the illegal use, acquisition
or distribution of a prescription or over-the-counter medication or
any mind-altering or addictive substance by an individual is prohibited
and, for these purposes, is deemed to be the use of such a medication
in a manner which is inconsistent with the instructions provided by
the manufacturer, pharmacist and/or the prescribing physician. In
addition, illegal use, acquisition, or distribution of any prescription
drug, over-the-counter medication, or any mind-altering and/or addictive
substance are strictly prohibited at any time. For example, it is
a violation of this Policy for an individual to use a prescription
or over-the-counter medication in a manner that is not consistent
with the intended and medically-prescribed use. |
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| To the extent that USAC in its sole discretion
determines that the use of any prescribed medication or other substance,
including properly prescribed prescription drugs and properly used
over-the-counter medications, causes an individual to have a diminished
or impaired ability to perform his or her duties on the day of an
Event, those substances shall be deemed to be prohibited substances
for purposes of this Policy. |
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| C. Alcohol |
| No Official or Competitor may consume
alcohol in the hours prior to or during an Event involving on track
activity, nor may any Official or Competitor be under the influence
of alcohol at any Event. "Under the influence," for purposes
of this Policy means that in the sole judgment of USAC the Official
or Competitor has an impaired ability due to alcohol consumption to
conduct himself or herself as USAC would expect at an Event. Nothing
in this paragraph shall preclude USAC from determining that a Competitor
or an Official with any alcohol usage, however minimal, is physically
unfit for driving, participating, or officiating in an Event. An alcohol
test by breathalyzer, blood test, or other scientifically-acceptable
method may be performed if deemed appropriate by USAC at its sole
discretion. In connection with the foregoing, USAC may take such action
as it deems appropriate. |
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| 2. Targeted
Testing for Reasonable Suspicion of Drug/Alcohol Use |
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| USAC may require a Competitor or Official
to submit to a test or tests, including without limitation, urine,
blood, saliva, hair, breath tests, and/or any other scientifically-acceptable
method of testing when USAC has reasonable suspicion that the Competitor
or Official has violated any part of this Policy or that he/she has
diminished ability to perform due to the use of any prohibited substance
or alcohol. Examples of the conditions, observations and/or reports
that may result in "reasonable suspicion" include, but are
not limited to, the following: |
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| A. |
When a Competitor or Official is
found or observed in possession of illegal drugs or drug paraphernalia
at any time; |
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| B. |
Observation of signs, symptoms and/or
behaviors that may be associated with the use of prohibited
substances or alcohol including, but not limited to: |
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| 1. |
Direct observation of an individual
engaged in drug-related or alcohol-related activity. |
| 2. |
Discovery or presence of prohibited
substances or alcohol in an individual's possession. |
| 3. |
Odor or residual odor associated
with prohibited substances or alcohol. |
| 4. |
Statements made by an individual
that may indicate that he/she uses prohibited substances or
alcohol. |
| 5. |
Red or droopy eyes, dilated or
constricted pupils. |
| 6. |
Slurred speech, stumbling, or hyperactivity. |
| 7. |
Needle marks or other physical
evidence that an individual has used a prohibited substance. |
| 8. |
Unexplained disappearances from
an Event. |
| 9. |
Nose constantly runs, appears red,
or persistent sniffling. |
| 10. |
Unexplained tardiness, absences,
or missed appointments; |
| 11. |
Chronic forgetfulness or broken
promises. |
| 12. |
Involvement in an accident during
an Event. |
| 13. |
Inability to concentrate, remember,
or maintain attention. |
| 14. |
Mental confusion, paranoia, or
expression of abnormal or threatening statements. |
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15.
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Violent tendencies, loss of temper,
or irritability. |
| 16. |
Unexplained or excessive negligence
or carelessness. |
| 17. |
Extreme, unusual, or unexplained
personality change, or unusual, irrational or erratic behavior. |
| 18. |
Deteriorating personal hygiene
or appearance. |
| 19. |
Pattern of abnormal conduct. |
| 20. |
Repeated failure to follow instructions
or operating procedures. |
| 21. |
Violation of USAC safety policies
or failure to follow safe practices. |
| 22. |
Display of any item that reflects
that the individual may be in violation of this Policy. |
| 23. |
Evidence that an individual has
tampered with or not cooperated with a prior drug or alcohol
test. |
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| C. |
An arrest or conviction for driving while under the influence
of alcohol or drugs, or a drug or alcohol related arrest or
conviction. |
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| D. |
Receipt of a report from a source deemed credible or reliable
by USAC that a Competitor or Official is under the influence
of drugs or alcohol on the day of an Event, or, at any time,
that an individual is in violation of this Policy. |
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| E. |
An examination or test, as provided by the USAC Rules, which
shows evidence of use of a prohibited substance or alcohol abuse
or of adulteration or manipulation of the specimen |
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| F. |
Aroma
of an alcoholic beverage or prohibited substance on or about
the breath or body of a Competitor or Official consistent with
use of a prohibited substance or alcohol. |
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| G. |
Following
an incident in which careless acts were observed in connection
with an Event. |
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| 3. Testing:
Scheduled and Random |
| At its sole discretion, USAC may require
Competitors or Officials to submit to an annual and/or random testing
for the use of a prohibited substance and/or alcohol. Selection of
individuals for random testing shall be done by USAC, at its sole
discretion. |
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| 4. Authorization
for Testing and Release |
| If, upon request by USAC, a Competitor
or Official refuses to promptly execute the authorization for testing
and release form enclosed with this Policy and deliver it to USAC
by the time designated by USAC for receipt, that Competitor or Official
will not be issued an USAC Competitor's or Official's license and/or
membership and, if already issued, the USAC license and/or membership
will be suspended until the Competitor or Official executes the above
mentioned authorization and release and delivers it USAC. If USAC
directs a Competitor or Official to submit to a test to determine
whether he/she is in violation of this Policy, that Competitor or
Official must consent to and promptly and fully participate in and
cooperate with the test in accordance with the instructions of USAC.
If that Competitor or Official refuses to promptly consent and/or
fully participate in and cooperate with such a test or tests within
the time period designated by USAC, USAC may eject the Competitor
or Official from the racing premises or take such other action as
may be appropriate, and that Competitor or Official will also be subject
to disciplinary action. |
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| 5. Screening |
| Annual random testing will be formal.
While random or targeted testing may be formal, USAC may conduct random
or targeted screening by USAC approved medical staff to determine
if formal testing is appropriate. |
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| 6. Collection
and Transport of Specimen(s) as to Formal Testing |
| USAC may designate specific USAC representatives
or USAC may designate others to be in charge of collection of specimen(s)
to be tested. Such designated individuals shall: |
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| A. |
Ensure that the specimen(s) are
from the Competitor or Official in question (including, where
necessary, observation of the collection of the specimen(s)). |
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| B. |
Ensure that the specimen(s) are
collected within the time period designated. Normally, collection
shall be made within one (1) hour or less of the notification
of the Competitor or Official that testing will be conducted,
unless a different time is designated by an Official based on
the circumstances. |
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| C. |
Ensure that the specimen(s) have
not been adulterated or manipulated by promptly measuring the
temperature of the specimen(s). Where results indicate that
the sample is inappropriate for testing, USAC may require the
Competitor or Official to provide additional specimen(s) as
necessary. |
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| D. |
Label, secure, and transport the
specimen (s) to USAC's designated testing facility in such a
manner as to ensure that the specimen(s) are not misplaced,
tampered with, or relabeled. |
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| E. |
Provide a form to be completed
by the Competitor or Official in question that identifies all
prescription and over-the-counter medications consumed by the
Competitor or Official in the preceding three months. |
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| 7. Facility
for Formal Testing |
| All testing will be performed at a facility
or facilities selected by USAC at its sole discretion. |
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| 8. Technological
Aspects of Testing |
| The USAC-designated testing facility will
determine whether and in what amount a particular specimen tests positive
with respect to a prohibited substance and/or alcohol, and whether
the specimen has been adulterated or manipulated. The testing facility
will transmit the results to USAC Director of Competition and to any
designated third party medical review facility. |
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| 9. Procedures
if a Test Shows the Presence of Prohibited Substances or Alcohol |
| A. With Respect
to Prohibited Substances Other Than Alcohol: |
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| 1. Upon being notified that a Competitor
or Official has tested "true positive" for a prohibited
substance, USAC's Director of Competition or his/her designee may
suspend that Competitor's or Official's USAC license and/or membership
for an indefinite period and/or take such other disciplinary action
deemed appropriate under the circumstances. |
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| 2. If that Competitor or Official wishes
to return to racing or officiating during or after the suspension
period, that Competitor or Official must submit to a re-test or re-tests.
This will be done at a time and place and under conditions specified
by USAC, at the Competitor's or Official's expense, which expense
will include laboratory fees and all other direct and indirect costs
incurred by USAC in connection with each test. If and when a Competitor's
or Official's test shows no evidence of a prohibited substance, that
Competitor or Official may be allowed to return to racing or officiating,
but only if he/she is not otherwise ineligible. Furthermore, if the
Competitor or Official does return to racing or officiating, he/she
shall be subject to future tests for any substance, drug or alcohol,
at such times and places as may be determined by USAC, at its sole
discretion, and at the expense of the Competitor or Official. |
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| B. With Respect
to Alcohol: |
| 1. Upon being notified that a Competitor
or Official has been determined to have consumed alcohol in violation
of this Policy, the USAC Director of Competition or his/her designee
may suspend that Competitor's or Official's USAC license and/or membership
for an indefinite period and/or take such other disciplinary action
deemed appropriate under the circumstances. |
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| 2. If a Competitor or Official does return
to racing or officiating during or after the suspension period, he/she
shall be subject to future tests for any substance, drug or alcohol,
at such times and places as may be determined by USAC, at its sole
discretion, and at the expense of the Competitor or Official. |
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| C. Testing Results |
| USAC may publish the results of any test
or tests conducted pursuant to this Policy and the circumstances giving
rise to such test to such third parties as USAC, in its sole discretion,
deems reasonable under the circumstances. The Competitor or Official
shall have no claim or cause of action of any kind against USAC or
any director, officer, employee or agent of USAC with respect to such
publication. It is the intent of USAC, and USAC will endeavor to,
treat the results of any test or tests as confidential as warranted
by the circumstances. |
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| 10. Falsification
or Withholding Information |
| Any Competitor or Official who attempts
to or does falsify, alter, or otherwise tamper with, adulterate or
manipulate any specimen or any aspect of a test performed under this
Policy will be subject to disciplinary action that USAC in its sole
discretion deems appropriate. A specimen that is identified as having
been adulterated or manipulated shall be treated in the same manner
as a "true positive" test result for a prohibited substance
other than alcohol, with all of the consequences of such a positive
test, including those provided in Paragraph 9.A. 1. and 2, above.
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| 11. Disciplinary
Action for Prohibited Acts Where There is No Evidence of or Testing
for Prohibited Substances or Alcohol |
| With respect to any prohibited act described
herein, if USAC determines that a Competitor or Official has engaged
in any such prohibited act, USAC may eject the Competitor or Official
from the premises or take such other action as deemed appropriate
by USAC in its sole discretion, and that Competitor or Official shall
also be subject to disciplinary action that USAC in its sole discretion
deems appropriate. |
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| 12. Treatment
for Drugs/Alcohol: |
| USAC does not provide drug or alcohol
rehabilitation programs. However, USAC strongly encourages self-help
and treatment for those who may have a drug or alcohol abuse problem.
Many worthy programs, both public and private, are available for the
treatment of drug and alcohol abuse. USAC will continue its efforts
to support a drug-free America and a society in which alcohol is not
abused. |
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| 13. Applicability
of the USAC Rules |
| This Policy, as it may be amended from
time to time, is a supplement to the provisions of the USAC Rules,
and will be interpreted and applied by USAC. This Policy is binding
upon all USAC members in the same manner and to the same extent as
are the provisions of the USAC Rules. |
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| Listing of Prohibited
Substances: |
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| Amphetamines |
Ephedrine
Class |
Narcotics |
Benzodiazepines |
Barbiturates |
| Amphetamine |
Ephedrine |
Alfentanil |
Alprazolam |
Amobarbital |
| Methamphetamine |
Psuedoephedrine |
Codeine |
Diazepam |
Butabarbital |
| MDMA |
Phenylpropanolamine |
Dihydrocodeine |
Lorazepam |
Pentobarbital |
| MDEA |
Fentanyl |
Oxazepam |
Phenobarbital |
| MDA |
Hydromorphone |
Temazepam |
Secobarbital |
| PMA |
Hydrocodone |
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Meperidine |
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| Other: |
Methadone |
Specimen
Validity: |
| Marijuana |
Morphine |
Nitrites |
| Cocaine/Crack |
Oxycodone |
Chromates |
| Meprobamate/Carisoprodol |
Propoxyphene |
Specific Gravity |
| Methylphenidate |
Sufentanil
|
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| Zolpidem |
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| USAC Substance
abuse policy authorization for testing and release |
| I have read the United States Auto Club
(USAC) Substance Abuse Policy. I hereby give my consent to USAC and
its designated agents to collect blood, urine, saliva, hair, and breath
specimens from me; and to screen and/or test those specimens for the
presence of alcohol and/or any prohibited substance under USAC's Substance
Abuse Policy; and to conduct such other tests as USAC deems necessary
from time to time to determine my fitness to participate in or at
an Event, all as set forth in the USAC Substance Abuse Policy as it
may be amended from time to time. In addition, I give my permission
to any doctor, nurse, technician, laboratory, or health facility which
administers drug or alcohol tests or screens to release the results
of any tests of examinations to USAC. |
| |
| I recognize that the USAC Substance Abuse
Policy has been adopted and is administered by USAC to promote the
integrity of USAC-sanctioned racing. Accordingly, I ALSO HEREBY RELEASE,
DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS USAC, its
officers, employees, representatives, agents, and testing facilities,
as well as any individual or company in any way affiliated with USAC
and any other persons or entities against whom I might have a claim,
from and/or for claims, damages, losses, or expenses of any kind,
whether caused by negligence or otherwise, arising out of the implementation
of the USAC Substance Abuse Policy, or any act or omission in connection
therewith, including and without limitation the testing of specimens
and the publication of the test results and circumstances giving rise
to such test or tests to any third party or parties by USAC or said
drug testing facilities, as well as the officers, employees, and agents
of each of them, or any other persons or entities. |
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I
have read and agree to the Annual Release and Waiver of Liability. |
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| Applications
must be filled out completely and accompanied by the required fees.
Applicants must provide an authorized signature below agreeing to
all terms of the license(s) for license to be processed. |
| Applicants Name Printed: ___________________________________________________________________________________________ |
| Signature: _______________________________________________________________________________________________________ |
| Date: __________________________________________________________________________________________________________ |
| Payment Information: |
| Amount Due: ____________________________________________________________________________________________________ |
| Check#_________________________________________________________________________________________________________ |
| Credit Card#:_____________________________________________________________________________________________________ |
| Expiration Date: ___________________________________________________________________________________________________ |
|
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| Office Use Only |
|
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| Paid by: Check # _____________ |
Cash _____________ |
Credit Card (Last 4#'s) _____________ |
| Amount Paid: _____________ |
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| Date Paid: _____________ |
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