11631 12th Road
Plymouth, IN 46563
(574) 936-0900
 
2016 REGISTRATION FORM
 
Car Number #: ________________ Rookie Candidate: ________________________________
Must compete in 70% of Plymouth Speedway’s Saturday
scheduled points events to qualify for points fund.
Must have less than 6 previous career starts in division
Register for Rookie Candidate by 2nd participating race weekend.
 
Class
(circle one):
Modified Pro Sprints Stree Stock Thunder stock 600 NW Sprints 410 Sprints
 
Driver's Name: ___________________________________________________________________________________________________
Street Address: __________________________________________________________________________________________________
City: ____________________________________________________________ State: _______________________ Zip: ______________
E-Mail Address: __________________________________________________________________________________________________
Phone: (_______) __________________________
Are you at least 18 years old?
(Circle One)
Yes No (Parental Release Required)
 
INFORMATION FOR: SOCIAL SECURITY OR TAX I.D. NUMBER OF PERSON OR ENTITY TO RECEIVE 1099
(PAYOFF CHECKS MADE OUT TO)
W-9 Required to Receive Check from Plymouth Speedway
 
Name or Entity: ___________________________________________________________________________________________________
Note: If owner/payee is same as driver just state “SAME”, note legal name is required for payee

E-mail Address: ___________________________________________________________________________________________________

Phone: (_______) __________________________
 
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Sponsors: _________________________________________________________________________________________________________


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Racing Accomplishments: (Championships, Tracks raced, Races won, Track records, Series raced in)______________________________________


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Disclaimer: I understand that my signature here makes me a member of Plymouth Speedway. I agree to abide by the racing rule book of Plymouth Speedway and its 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 Plymouth 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.

*Note: Checks will be made payable to the person listed on your registration form as the recipient of the 1099.

 
Signature: __________________________________________________________ Date: ________________________________
 
Plymouth Speedway
Plymouth, Indiana
Copyright © 2010 - 2016 Plymouth Motor Speedway
All Rights Reserved