Car Number & Driver Information

                                                -PLEASE PRINT-

DRIVER NAME: ______________________________________ Car Number: _________

Social Security #: __________-_____-__________

Address: ____________________________

City: ______________________ State: ______________ Zip Code: ____________

Home Phone: (_____)-_______-_________  Work Phone: (_____)-_______-_________

Cell Phone:    (_____)-_______-_________Email Address: ____________________@____________.com

RACING CLASS (please circle):

A-MODIFIED  /  BOMBER  /  SUPER STOCK  /  B-MODIFIED  / LATE MODEL (series-___________)  /   MOTORCYCLE /  305 WINGED SPRINT  /  360 WINGED SPRINT  /  FACTORY STOCK  /  ENDURO CAR /   MINI-STOCK  /  MIDGET  /  4-WHEELER (ATV)  /  GO-KART   

REPORT EARNINGS UNDER:

Name: ________________________________________________

(MUST BE EXACTLY THE SAME AS SECURITY CARD/FEDERAL ID)

Social Security Number: ______-___-______ OR Federal ID Number: _______________________

Address of Payee: ________________________City: _________________ State: ___Zip Code: __________

SPONSORS:

1)_______________________________ Location: _________________________

2)_______________________________ Location: _________________________

3)_______________________________ Location: _________________________

4)_______________________________ Location: _________________________

5)_______________________________ Location: _________________________

RACING TEAM:

Crew Chief: ______________________________ Phone: (_____)-_______-_________

Crew Members:

1)_______________________________  4)_________________________

2)_______________________________  5)_________________________

3)_______________________________  6)_________________________

PERSONAL INFO

Spouse Name: ______________Children (ages) _________________________________________________

_________________________________________________________________________________________

Occupation: ___________________ Hobbies: ___________________________________________________

Additional Info / Comments: _________________________________________________________________

________________________________________________________________________________________

If you would like you could mail your form to us.

Mail your form to:

Midway Speedway

20377 Silver Drive

Lebanon, Mo.   65536 

_______________________________________                                               ____________________

Signature                                                                                                             Date