2006 Race of Champions Asphalt Modified Tour Membership Application

Applicant Name: ___________________________________________ Car #: _____________

(car numbers will not be assigned until roc office receives receipt of paid membership application)

Applicant Address: _____________________________________________________________

(please print and fill out completely)

__________________________Zip Code: ______________ S.S #: _______-______-______

Birth Date: ____/____/____ Phone Numbers: (h) __________________ (w) _________________

Cell Phone Number: ___________________ Email Address: __________________________

Driver Website: ______________________ Other Car # Choices: _____________________

Car Owner: ____________________________ S.S #: _______ - _______ - _______

Owner Address: _____________________________________________ Zip Code: __________

Phone Numbers: (h) ____________________ (w) __________________ (c) ___________________

THE PERSON THAT ANY PURSE OR POINT FUND MONIES ARE PAID TO SHOULD BE LISTED

ABOVE AS CAR OWNER WITH COMPLETE INFORMATION PROVIDED.

Every driver competing in one or all events must file a tour membership application. A Race of Champions Membership Card will be sent to each driver for identification purposes.

Crew Members may purchase a discounted membership making them eligible for possible admission discounts and other contingency programs. All members will have one vote for regional and overall “crew member of the year” awards.

Please Check One: Crew Membership: $30 __________ (includes both regions)

Driver Membership: 1 Region: $60 __________ 2 Regions: $100 __________

If purchasing membership for only 1 region please indicate which region here: ______________

IN CONSIDERATION of the acceptance of this Race of Champions Modified Tour Membership Form, I for myself, my heirs, next of kin, personal representatives and assigns, FOREVER RELEASE, REMISE and FOREVER DISCHARGE and AGREE TO HOLD HARMLESS and INDEMNIFY the promoters presenting races or other events, the owners (lessors) of the premises at which these events are held, the participants, theron, and the owners, sponsors and manufacturers of all racing equipment used in any of these events, the officers, directors, agents, employees and servants of all of them, including officials and Race of Champions Modified Tour members, of and from all liability, claims, action and of possible causes of action whatsoever. Including negligence of any of the foregoing, that may accrue to me or my heirs, next of kin and personal representatives from every and any loss, damage and injury, including death, that may be sustained by my person and property while in or about and enroute into and out of any Race of Champions Modified Tour event.

By Signing this 2006 Race of Champions Modified Tour membership Form I acknowledge that I have read the entire form and understand its contents. The Race of Champions Modified Tour has consent to use driver name and likeness for promotional and souvenir materials. This Race of Champions Membership may be revoked at any time for failure to adhere to tour rules, implied or assessed.

Applicant Signature: _____________________________ Date Signed: _______________

Checks may be made payable to: Race of Champions, P.O. Box 2828 – Binghamton, New York 13902. Forms may be faxed to (607) 775-3417 or (607) 775-3393 however car numbers will not be assigned until payments are received at the r.o.c offices. For further information please phone: (607) 775-5555 or (607) 238-0432 or log on to www.raceofchampions.net. Cell phone and email information is requested to help inform members if the situation of an event rainout or cancellation should occur.