Midwest Region October Fundraiser Registration Form

Sanction(s): All: Sat + Sun 12 events if paid by 9/28, Sat only 6 events if paid by 9/28, Sun only 6 events if paid by 9/28
Entrant # 1 Car Number: Registration $
Entrant # 2 Car Number: Registration $
 Total$

1 Personal Information
 
Entrant # 1:
NCCC number:      
(Format: RR-CCC-MMMM)
First: Last:
Address:
City: State: Zip:
Phone: Email:
 
Entrant # 2:
NCCC number:      
(Format: RR-CCC-MMMM)
First: Last:
Address:
City: State: Zip:
Phone: Email:
 

2 Car InformationNon-Corvettes are either Metal (Men's Class) or LMetal (Ladies Class) and are NOT included in NCCC Results.
 Entrant #1:Entrant #2:
  Year: Make: Model: Class:          Year: Make: Model: Class:         

3 Events
All: Sat + Sun 12 events if paid by 9/28 Entrant 1: $100.00                                                                     All: Sat + Sun 12 events if paid by 9/28 Entrant 2: $100.00                                                                     
Sat only 6 events if paid by 9/28 Entrant 1: $50.00                                                                     Sat only 6 events if paid by 9/28 Entrant 2: $50.00                                                                     
Sun only 6 events if paid by 9/28 Entrant 1: $50.00                                                                     Sun only 6 events if paid by 9/28 Entrant 2: $50.00