Requested car #_______ Car # rec'd:

ENTRANT LICENSE AND INSURANCE BENEFIT PLAN CONTRACT

2003 Dixie Motor Speedway License Registration Racer Card # Owner #

In order to collect winnings driver or owner must show their card, only driver

or owner may pick up winnings unless prior arraignments have been made! Date paid $ cash ck#

Type of registration-Circle one )

Driver / Driver/Owner Owners Name Mandatory if different from drivers name-Owner must fill out-Owner Registration-for all Dixie drivers who will participate in points & competition at D.M.S. (look below for registration cost-same as driver)

LM $35.00; Mods $35.00; FS $30.00; Fig 8 $30.00; Pro 4's $20.00; F-4's $20.00; SLM $50.00

(circle one) if applying for more than one division must fill out additional registration form

How many years Racing?_________ Rookie (have you ever driven in this division before at Dixie) if yes how many races?____ ______

NAME, Last ________ ______ First ____ ___ _____M Age _ ____Spouses Name

Residence Address: ____ City ______________________ State ________ Zip

Driver’s License #___________________________________ Date of Birth Social Security #

phone #’s home ( ) Work ( ) Cell # ( )

Employer Address Your Occupation

Employer city /State/zip

Date of Last Physical Physical Condition Any Handicaps or Disabilities? YES / NO

*If Yes: Describe

Do you have Health Insurance? Type: Name of Company any allergies: yes / no

If yes, to what Are you taking medication yes / no if yes-what medication and

why? Doctors Name city

email Address__________________________________________@ _____________.com ; . net ; . org; . biz

BENEFICIARY STATEMENT: I hereby designate and name as Beneficiary Spouse Parent Child Other/Name

phone # ( ) Car Owner information Driver will receive 1099 unless OWNER form is filled out

AGREEMENT

Racing is a Dangerous Sport. Injury and/or death can result from racing related activities. As a participating car owner, driver, spectator, mechanic, employee, official, sponsor or independent contractor, I agree that the track & pit areas are in safe condition if I take part in racing activities, and that I have been given no implied or expressed warranty of safety.

I understand that my signature along with the registration fee, and acceptance of this application by the D.M.S. makes me a member of the D.M.S. club and entitles me to the benefits thereof.

I understand that as a registered member of D.M.S., I and my heirs and assigns will be entitled to the Competitor Accident Insurance Policy procured by D.M.S. for accidental injury or death sustained in D.M.S. events, provided proper notice is given to D.M.S. The policy coverages in force shall be considered the limit of liability of D.M.S. for injury or death occurring to me in any D.M.S. event.

I also understand that as a member of D.M.S. I am eligible to compete for the drivers point championship and point fund. I understand that in order to receive point fund winnings, I must attend the annual awards banquet.

I certify that I am an independent contractor and not an employee of D.M.S. I assume all financial responsibilities including, but not limited to, withholdings tax, income tax & workmen’s compensation insurance with regard to any monies received from D.M.S.

Any driver or crewmembers leaving their own pit area and involved in a fight will be immediately fined $250.00. If that amount is not paid immediately, the fine will be raised to $500.00, and that individual, as well as driver will not be allowed in pit area until fine has been paid. If driver refuses to pay fine immediately all points will be forfeited for that night. Unsportsmanlike conduct will not be tolerated under any circumstance and will result in immediate removal, suspension and/or fine from D.M.S.

Any dispute, controversy or claim involving the undersigned member shall be settled in accordance with existing and/or amended rules and regulations of D.M.S., and I agree to accept the decisions rendered in the process. Disputed decisions may be appealed, in writing to the Speedway office within 5 days. Upon appeal, D.M.S. decisions are final. Drivers agree to be responsible for ALL crewmembers, registered or unregistered. D.M.S. reserves the right to adjust division rules, including weight, in the interest of fair and competitive racing. D.M.S also reserves the right to amend or modify Speedway policies, rules and regulations as may be needed.

I consent to the use of my name and/or pictures of me and my car for publicity, advertising and endorsements, and relinquish any rights to photos taken in connection with racing activities and consent to the publication or sale of such photos by D.M.S.

I AGREE TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES AND REGULATIONS OF DIXIE MOTOR SPEEDWAY AS NOW PUBLISHED, OR AMENDED IN THE FUTURE. I AGREE NOT TO ENGAGE IN ANY ACTIVITY THAT WOULD DISRUPT OR INHIBIT RACING AT D.M.S. BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. I AGREE THAT IN THE EVENT I BREACH THIS AGREEMENT, I AM LIABLE FOR ACTUAL AND LIQUIDATED DAMAGES SUSTAINED BY THE SPEEDWAY AS A RESULT OF SUCH BREACH.

Dated: Day of ,2003 legal signature:

Witness Signature:

If applicant is under 18 years of age, a minor/parent Release must be executed and filed with this application

Please return dated & signed form with check or money order to: Dixie Speedway;10945 Dixie Hwy; Birch Run, MI 48415989.624.9778; Fax 989.624.9570

1099 TAX INFORMATION (FOR CAR OWNERS)

2003 Dixie Motor Speedway Registration OWNER Form

Car Owner-1099 recipient must complete this form if different from driver information

ENTRANT CAR OWNER AND INSURANCE BENEFIT PLAN CONTRACT

Owner - Mandatory for all Dixie owners whose drivers will participate in points competition at Dixie Motor Speedway

circle one: Late Model $35.00; Mods $35.00; Factory Stock $30.00; Fig 8 $30.00; 4 Cyl $20.00 Super Late Model $50.00

NAME, Last ________ ______ First ____ ___ ______ __ M Age Spouses Name

Residence Address: ____ City ______________________ State _ _ _ Zip

Driver’s License #_________________________________ Date of Birth Social Security #

phone #’s home ( ) Work ( ) Cell # ( )

Employer Address Your Occupation

Employer city /State/zip

Date of Last Physical Physical Condition Any Handicaps or Disabilities ? YES / NO

*If Yes: Describe

Do you have Health Insurance? Type: Name of Company any allergies: yes / no

If yes, to what Are you taking medication yes / no if yes-what medication & why?

Doctors Name city

email Address__________________________________________@ _____________.com ; . net ; . org; . biz

BENEFICIARY STATEMENT: I hereby designate and name as Beneficiary Spouse Parent Child Other/Name

phone # ( ) AGREEMENT

I understand that my signature along with the registration fee, and acceptance of this application by the D.M.S. makes me a member of the D.M.S. club and entitles me to the benefits thereof.

Please return this form signed, dated & check or money order to: Dixie Motor Speedway;10945 Dixie Hwy; Birch Run, MI 48415;989.624.9778; Fax 989.624.9570

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