Nor-Cal Dwarf Car Association
C/O Connie Bender
6095 Rainier ave
Rocklin, Ca. 95677
209)836-4722 (Jan)
2008 Membership Application
CAR
OWNER:_______________________________________________________
ADDRESS:____________________________________________________________
CITY___________________ STATE:____________________
ZIP:___________
PHONE #:_______________________CELL
#________________________________
EMAIL ADDRESS:____________________________________________
SOC. SEC#: _______________________ (Of Payee-Please indicate if driver or spouse)
DRIVER'S NAME (if different from
owner)_______________________________
DRIVER'S SPOUSE
NAME:_________________________________________
DRIVER BIRTHDATE:_______________SPOUSE
BIRTHDATE:_________________
CAR OWNERS BIRTHDATE (if different from
driver)_____________________
CAR YEAR/BODY
STYLE:________________________________________________
CAR # 1ST
CHOICE: ________ 2NDCHOICE________ 3RD
CHOICE_________
SPONSOR'S:___________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
PREVIOUS EXPERIENCE:________________________________________________
______________________________________________________________________
ANNUAL DUES: $100.00 (Includes
owner's card and driver's card)
each. Membership expires 11/31.
I hereby apply for membership in the N.C.D.C.A.
Liability
release: In consideration of the acceptance of the right to participate,
entrants, participants, and spectator's, by the execution of this form,
release, and discharge the NCDCA and their officer's director's, employees,
agents, representatives, members, and servants and anyone else connected with
the management for this event of and from any and all injuries and damages,
whether the same is known or unknown, inquires, losses, judgements, and or
claims from any causes or damages whatsoever that may be suffered by an entrant
to his person or property. Further,
each entrant, participant, or spectator expressly agrees to indemnify and hold
harmless all of the foregoing entities, firms, persons, and bodies of and from
any and all liability occasioned or resulting from the conduct of entrants or
any and all liability occasioned or resulting from the conduct of entrants or
any participants assisting or cooperating with entrant or any participants
assisiting or cooperating with entrant and under the direction and control of
entrant.
SIGNATURE OF
APPLICANT:________________________DATE:_______________