SCCA Divisional PRO Rally
License Application
 

APPLYING FOR: _____Initial ______Renewal

Type or print
Please read instructions before completing this application.

NAME_______________________________________________________________________________

ADDRESS____________________________________________________________________________

CITY__________________________________ STATE___________________ ZIP__________________

TELEPHONE (h) (______)_________________ (W) (______)___________________________________

DATE OF BIRTH_______/________/________ SSN_____________/_____________/________________

MEMBNO_________________ EXP_________ DIV_________________ REG_____________________

DRIVERS LICENSE # __________________________ STATE_________ EXP_____________________

RECORD OF RACE PARTICIPATION - Must complete!
You need list only those events which meet the participation requirements stated in the instructions.

DATE _____________EVENT*________________LOCATION _______________FINISH
_____/____/____ _______________________________________________________________________
____/____/_____ _______________________________________________________________________
____________________*Please list type of event, PRO Rally School, Divisional, or National.

_________________________________________ OR ______________________________________
__Divisional PRO Rally Steward Signature / Date _____________Licensing Seminar Instructor / Date
I, the undersigned, hereby make application to the Sports Car Club of America, Inc., for the issuance of an SCCA National PRO Rally competitor's license. I hereby certify
that the above information is true and correct. I further certify that I am familiar with the rules and regulations governing the use of the indicated license and I agree to be 
bound by those rules and regulations and all applicable SCCA policies.

______________________________________________________ ______________________________/_______/_______

Applicant's Signature _____________________________________________________________________ Date

IF THE APPLICANT IS UNDER 18, PLEASE COMPLETE THE FOLLOWING:
I, being the parent or legal guardian of the above named minor applicant, acknowledge that he/she is applying for alicense to 
participate as a competition driver in SCCA PRO Rally events.

____________________________________________ _________________________________________/_______/_______
________Parent or Legal Guardian's Signature ____________________________________________________Date

Official Use Only
Date Rc'd _________/__________/___________ ________License Fee: $60.00 ____Ck # ________________
MC/Visa ____________________________________________________________ Exp _________________