Cal Club
Double Regional/TimeTrial
October 1-2, 2011

2005 Entry Form

	

Event: 
Dbl Reg/Time Trial	Date:
Oct 1-2, 2011
	Late Entry Deadline:
Sept. 25, 2011	Sanction #:
11-R-1733-S/11-R-1734-S/11-CT-1735-S	Track / Location:
BUTTONWILLOW RACEWAY PARK
25 A Clockwise 3.2 Miles

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 2011 General Competition Rules & California Sports Car Club 2011 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/SM
Fee  per Race:	Late -Fees:
9-25-2011	Total Fees:	PLEASE SEND ENTRY TO:
 Club Registrar
4743 Canehill Ave.
Lakewood, CA 90713

Phone:  661.304-9382
Fax:      562-421-4598
E-Mail: calclubhq@aol.com
	
Dbl.   Regional
Single Regional
Dbl Regional/Dbl Dip
Single Reg/Dbl Dip
Time Trial
Time Trial Single Day
Worker Donation	$330.00
$230.00
$490.00
$330.00
$200.00
$125.00

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

TOTAL	
$ ________________
$ ________________
$ ________________
$ ________________
$ ________________
$ _________________
$ _________________