California Sports Car Club
Double Regional
June 12-13,2010

2005 Entry Form

Event: 
Double Regional	Date:
June 12-13,2010
	Late Entry Deadline:
June 6, 2010	Sanction #:
10-R-1145-S/
10-R-1146-S/
10-CT-1158-S
	Track / Location:
Auto Club Speedway	
 		
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 	
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 	Late Fees:
After 6-6-2010	
Total Fees:	PLEASE SEND ENTRY TO:

Cal Club Registrar
4743 Canehill Ave.
Lakewood, CA 90713

Phone:  661.304-9382
Fax:      562-421-4598

E-Mail: 
calclubhq@aol.com

Double Regional
Double Regional/Double Dip
Single Regional
Garage- Single Space
Garage- Full
Time Trial	$370
$550
$290
$100.00
$200.00
$165.00	………$20……………$20……	…….$40.00……..
…….$40.00……..
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Worker Donation:

TOTAL	$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
 
$ ___________

$ ___________