DEMO REGISTRATION

Spring Shootout Demo Derby Registration

Event: April 28th, 2012; 1:00p.m.; Stockton, KS.

Pre-register by April 15^th and pay:

$70.00 for car and driver (80's and Newer) ;

$50.00 for car and driver (Compact class and Pickups)

Checks payable to: Chad Sterling (Money orders preferred)

Mail to: Chad Sterling, 606 N. Cypress, Stockton, KS 67669

and $65.00 for car and driver (Compact Class and Pickups)

NO CHECKS ACCEPTED THE DAY OF THE DERBY!

Name: ___________________________________

Address:______________________________

Phone:____________________________

Car #: ______________

Sponsors:______________________________

______________________________________

_______________________________________

Person responsible for paying taxes, if applicable:

Name: _________________________________

Address:______________________________________________

Social Security Number: ______________________________