2009 Coca Cola Late Model Nationals
Pre-Registration
$75.00 car entry - $20.00 per person pit passes
Car #_________
Driver’s Name:______________________________________ Driver’s SSN:_____________________
Driver’s
Address:________________________________________________________
City:
Phone #:____________________________
Email:_______________________________
Any Driver under the age of 18 must have a minor release form completed by parent or guardian and a Copy of his/her birth
certificate on file at the track office.
Make checks payable to: Driver or Owner (We must have a
social security # or federal ID #)
Owner’s Name:_____________________________________ Owner’s SSN:__________________________
Owner’s
Address:_________________________________________________________
City:
Phone #:_________________________________ Email:_________________________________
Car Registration Fee $75.00
Early Pit Pass Fee $20.00
Make checks payable to Wagner
Speedway
Mail
to:
Wagner
P.O. Box 787
Wagner,
SD 57380