Event: 
 Double Regional
	Date:
October 16-17,2010
	Late Entry Deadline:
October 10, 2010	Sanction #:
	Track / Location:
BUTTONWILLOW RACEWAY PARK
25A CW	
 		
Log Book ID
	Make
	Model
	Year
	Color
	Class
	Car Number Choices	
						1st  	2nd  	3rd  	
Transponder # - Required  	E-mail
	Registrar Use
Only	
Driver's Name (Please print legibly)
	Daytime Phone
	Run Group	
Address
	Evening
	Car #	
City
	State
	Zip Code
	Fax
	Class	
Membership Number
	Expiration Date
	License Grade
 Reg   Nat   Dual   FIA   Novice 	Member/License OK	
Region of Record
	Cal Club Associate or Lifetime Member?       Yes   No	If Renting, From Whom?
	Tech Card Given?	
Entrant ( if different than driver )
Name
Address
City, State, Zip	Entrant Member #  AND Expiration Date	Waiver Signed?

		Payment Type:

 Cash
 Check #
 Credit Card

Total Paid

$___________

Registrar Initials	
Sponsor(s) 		
In Emergency, notify?
	Phone
	At Track?
Yes      No		
Circle Payment Type, Payable at Registration (PLEASE, bring card to registration.)                               Check	    Visa	          MasterCard 	     Cash
Card #______________________________________________Expiration Date:______________ 			

It is agreed that the entry, if accepted, shall be a contract between the Driver/Entrant & the SCCA/California Sports Car Club Region under which the above car & driver will take part in the competition described, unless prevented by force beyond control of the Driver/Entrant.  This event will be conducted under the SCCA 2010 General Competition Rules & California Sports Car Club 2010 Supplementary Regulations and the Entrant & Driver agree to abide by these rules. All participants must sign a release agreement at Registration before entering the track facility.	

Driver Signature _____________________________________    Entrant Signature  ________________________________________	
	Entry Fees:	SRF /FE
Fee  per Race:	Late -Fees:
10-11-10	Total Fees:	PLEASE SEND ENTRY TO:

Cal Club Registrar
4743 Canehill Ave.
Lakewood, CA 90713

Phone:  661.764.5945
Fax:      562-421-4598
E-Mail: calclubhq@aol.com

Dbl.   Regional
Single Regional
Dbl Regional/Dbl Dip
	
$330.00
$230.00
$490.00

$10.00 per race
$10.00 per race
	
$40.00
$40.00

Worker Donation
TOTAL	
$ ________________
$ ________________
$ ________________
$ ________________
$ ________________
$ ________________		

Cal Club Region of SCCA
Double Regional- Pumpkin Run
October 16-17,2010
Buttonwillow Raceway Park  25ACW