24 RACEWAY, LLC

2010

TRACK MEMBERSHIP FORM

Driver Name____________________________Birth Date_________

Address________________________________________________

City_____________________State____________Zip____________

Home Phone_______________Work Phone______________________ 

Social Security # (REQUIRED)_______________________________

Email Address____________________________________________

WHO THE CHECK GOES TO_________________________________

Car Owner Name__________________________Birth Date________

Address________________________________________________

City_______________________State___________Zip___________

Home Phone________________Work Phone_____________________

Social Security # (REQUIRED)________________________________

Email Address____________________________________________

Membership Fee and Car Number

______A MOD   $50 Car#________          _______   Sportsman         $40 Car#_________

            _______B MOD   $40 Car#________         

______Hornet     $40 Car#________          _______   Hobby Stock      $40 Car#_________

2010 Pad Rental $100-  PAD#_______________ Concrete pads will be held for renewal until

Feb 28th after that, they will be rented on a first come first serve basis.

I understand that I am an independent contractor, and that I am responsible for all tax

withholdings, FICA and self-employment taxes.

Date_____________________Signature___________________________________________

All drivers must furnish a valid drivers license and social security number.

      Checks payable to :                    Twenty Four Raceway, LLC

P O Box 553

Moberly, Mo  65270-0553

Phone: 660-269-9300

Track memberships are required for all 24 Raceway competitors. Car numbers are given on a first come, first served basis.

24 Raceway reserves the right to use a drivers name, picture and car in all advertising.