Car # ___________   Class__________       
Fee Paid________      Postmark_________

Dryad - Shitepoke Rally Entry Form

Make checks payable to Pacific Rally Group.  Mail entry to 1405 Harrison, Suite 203, Olympia, WA 98502 or FAX to 360-956-9041. All Competitor and Service Crew members are required to sign the waiver prior to the start of the event. Entry is not complete unless all information is provided.
Driver Information                      Entering: Saturday____  Sunday____  Checklist
Name______________________________________________________________  Reistrar
Initials _____
Address____________________________________________________________ Driver License_____ 
City____________________________________   State_____  Zip____________   NASA Mbr___
Telephone__________________             e-mail:___________________________    Comp Lic ____
Drivers License #_________________________  State_____   Exp._____
NASA Membership #_________________  Competition License # ___________ Co-driver
License _____ 
Emergency Contact:_____________________________________ At event? Y/N NASA Mbr____
Co-Driver Information


Name__________________________________________________________         

 Comp Lic____
Address____________________________________________________________
City____________________________________   State_____  Zip____________   Vehicle
 Ins. & Reg.
Telephone__________________; e-mail:___________________________    Rally car_____
Drivers License #_________________________  State_____   Exp._____ Service   _____
NASA Membership #_________________  Competition License # ___________
Emergency Contact:_____________________________________ At event? Y/N Waiver signed
Vehicle Information
 Car # _____   Car Class _______Year_______ Make_____________________		 Driver _____  
Model_______________________________    Color ____________ 
Engine Displacement ___________ 		 Co-Driver _____
Sponsors_________________________________________________________ Crew _____
Insured by____________________________ Policy Number__________________
Insurance Warranty - I warrant that the competition vehicle and all service vehicles(for the competition vehicle), have current minimum liability insurance coverage of $100,000/$200,000/$50,000.


__________________________________________________________________
Vehicle Owner Signature             / Printed Name               / Date
Read and Sign: I agree to compete under the current Pacific Rally Group rules  and the supplementary rules for this event(s). I further affirm that the car I have entered complies with all the requirements for the class and category in which it is listed above. Driver and car owner agree to permit the use of their names, voice, likeness of themselves and their vehicles for new features and publicity articles used by all forms of media  sponsor advertising, event promotion, and other purposes of trade without compensation to the driver or owner.