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:_______________

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Mail this form along with your check or money order to: Edmond Richardson Motorsports 2665 Bellar Rd Ext. Greenbrier, Tn. 37073