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File Added 4/26/2014 11:17:00 AM

2014 Driver Registration Form

DRIVER REGISTRATION #_________________________ 2014 CANEY VALLEY SPEEWAY / DRIVER REGISTRATION PLEASE PRINT LEGIBLY NUMBER REGISTRATION 1st choice__________ 2nd choice__________ Please Circle you car class: B Modified Micro Late Model Pure Stock Factory Stock Jacket Size____________ Driverís Name___________________________________ Age_________ Social Security Number:_________________________________________ Home Phone:_____________________ Cell Phone:___________________ E-mail:_______________________________________________________ Driverís Address:_______________________________________________ City:_____________________State:_______________Zip Code:_________ CAR INFORMATION: Car Owner:_________________________Phone:_____________________ Social Security Number__________________________________________ EMERGENCY INFORMATION: Contacts:____________________________Phone:____________________ Medical Conditions or Allergies:___________________________________ Competitorís Signature__________________________________________ CANEY VALLEY SPEEDWAY FEE $30.00 Make checks payable to:Kerry Gorby Mail form and money to:1520 CR 2400 Havana, KS 67347

                                                                                                                                                  
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