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EDGE Driver Application.pdf

EDGE Driver Application.pdf

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Published by: Cody Watson on Dec 12, 2012
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2012 EDGE Competitor License Application

Driver Name: _____________________________________________ Car #:________________
Mailing Address (House # or P.O. Box): _______________________________________________
City: ______________________________________ State: _____________ Zip: _____________
Social Security #: ________________ Birthday: ______________ Home Phone:______________
Email: ______________________________________ Home track: ________________________
Class Participating In: _________________________________ Shirt Size: __________________
Sponsors:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Fill out the following Information if different from the Driver:
Checks Payable To: _____________________________ S.S # or Tax ID #: ___________________
Mailing Address: ______________________________________ Home Phone: ______________
City: ___________________________________ ___ State: _____________ Zip:_____________
Make checks payable to EDGE and mail to: P.O. Box 107, Middlebourne, WV 26149
For credit card purchases, please complete the following:
Name On Card: ________________________________________________________________
Card Number: _________________________________________________________________
Expiration Date: ____________________________ CVC #: _____________(Three Digit Number on Back of Card)
Wavier of Liability
By signing the registration form you are agreeing to abide by the rules, regulations, and penalties of the
Tri-State Modified Association. You also give TSMA and/or sponsors permission to use your name and/
or image without further compensation to you or your team for its use. You are giving your permission
to allow TSMA to use the information provided in any way TSMA deems necessary. This is a dangerous
sport, you could be injured or killed. You are risking your life by participating in any fashion. By sign-
ing you agree that you and/or family will not sue TSMA, officers, sponsors, and officials. The TSMA,
and/or representatives are not responsible for any accident, loss, injury or death which may or may not
occur while attending, participating in, or a sanctioned event. The TSMA, officers, promoters, members,
officials, sponsors, will not be held responsible or liable for injury or death. The rules which are used in
this sanction are intended only for the orderly conduct of a racing event, and should not be interpreted
or construed to warrant and/or guarantee safety in any way.
DRIVERS SIGNATURE _____________________________________ Date _________
Entering false information on this form is a Federal offense and will cause explusion from
TSMA, and legal action will be taken according to Federal Law
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[ ] $75 Modified [ ] $50 Crate [ ] $40 Hot mod [ ] $15 Temp. License
If Temporary License, What Division: _______________________________

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