Clinton County Raceway Driver Registration

Please Complete, Print, Sign and Mail To:	Vern Wassen PO Box 821 Jersey Shore, Pa 17740

Please Complete, Print, Sign and Mail To:

Vern Wassen
PO Box 821
Jersey Shore, Pa 17740

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Driver Name:
Address:
Home Phone:
Alternate Phone:
Email Address:
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Social Security Number:
Date of Birth :
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Spouse:
Children & Ages:
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Emergency Contact:
Emergency Phone:
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Alternate Prize Money Clamier:
Social Security Number:
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Class of Competition:
Car Number Requested:
Primary Sponsors:

Signed____________________________________________ Date_________________