AMSRA
National Championships Racer Registration Form
February 24-25-26, 2005
Racer name: ____________________________________________________________
First Last
Address: _____________________________________________________________
Street Apt.
_____________________________________________________________
City State Zip
Contact Info: _____________________________________________________________
Telephone Email
Classes you will race: 4.5 Nascar Junior Nascar 4.0 Nascar GT-1 GTP GT-12
(Circle all that apply) (under 14)
Will you be racing Amateur or expert? AmateurExpertUncertain
Racing organizations you are currently a member of: AMSRA USRA ISRA USSCA
(Circle all that apply)
To pre-register and reserve your pit space prior to your arrival, please send this form along with a check for $15.00 (the fee will
be applied to your race fees upon arrival) to Lou Cicconi, 300 Governor Printz Blvd. Lester, PA 19029. ____ Check here if
you are sending a check for reserved pit space.
If you are not reserving pit space please fill out this form and fax it to 610-521-1981. Your information helps us with our
pre-race planning. You can also email this form to: liq75@aol.com Thank you.
For any other questions, if you need car specs, directions to the race, or anything else, please call Lou Cicconi at:
610-496-6700, or email him at LIQ75@aol.com
Seeya at the races!
