REGISTRATION FORM

Name: ________________________________________________________

Address:________________________City:_______________ State:_________ Zip:_______

Age:______ Weight:_____  Height:_______  Date: of Class You Are Attending:____________

Home Phone: (________)  _________________________

Work Phone: (________)  _________________________

Please check the class you wish to attend

[   ]   Quick Rod/Super Comp Class  (dragster)      circle one 3-day $2,390    2-day  $1,990

[   ]   Super Rod/Super Gas Class  (door car)         circle one 3-day $2,390   2-day $1,990

[   ]   Bring Your Own Car                                     circle one 3-day $1,390   2-day $1,190

[   ]   IHRA/NHRA License Class    $895

[   ]   Jr Dragster   $690

Note: A non-refundable deposit in the amount of $500 is required for pre-registration. The balance of your account will be due and payable upon the first day of class.

Prices subject to change without notice.

Method of Payment: [  ]Personal Check#_____  [  ]Visa  [  ]Mastercard  [  ]Money Order

Please make check payable to: Edmond Richardson School of Drag Racing

If you are paying with your Visa or Mastercard, please complete the information below.

Name as it appears on the card:__________________________________

Billing Address if different from above:_____________________________________

Credit Card Number: _ _ _ _ -_ _ _ _ - _ _ _ _ - _ _ _ _       Exp Date: _ _ / _ _

Signature:__________________________________  Date:_______________

--------------------------------------------------------------------------------------------------

Mail this form along with your check or money order to: Edmond Richardson Motorsports 8010 Anna Ct Greenbrier, Tn. 37073

Return to Edmond Richardson's School of Drag Racing

To print this form click on file in the upper left corner, then click print.