2013 Tirerack Cannonball One Lap of America Entry Application

The event rules and regulations should be studied and understood before filing this application. Questions concerning application filing can be dealt with before submission by calling Cannonball Circuits, LLC at

(610) 983-3379 Please include a phone number with all written requests for information.

Cannonball Circuits, LLC 1415 State Road, Phoenixville PA 19460

 

Entrant Information

Driver/Team Captain

Name:_____________________________________________________ 

Address:___________________________________________________

City/State:__________________________________________________

Zip:_________________________   email:_______________________

Daytime phone:_______________________fax:____________________

DOB:_________________________                                    

Driver’s License No:___________________________State:_________    

License Exp. Date:____________________________________________

NASA Membership No:________________________________________

NASA Membership Exp. Date:___________________________________

Driving Background (experience, schools, etc.):________________ 

__________________________________________________________  

Insurance Carrier:____________________________________________

Policy No:__________________________________________________

Policy Dates:________________________________________________

Description of Liability Coverage:____________________________

Driver 2

Name:_____________________________________________________

Address:___________________________________________________

City/State:_________________________________________________

Zip:__________________________   email:_______________________

Daytime phone:_______________________fax:____________________

DOB:_________________                                             

Driver’s License No:__________________________State:____________

License Exp. Date:____________________________________________

 

Driver 2 (continued)

NASA Membership No:______________________________________

NASA Membership Exp. Date:________________________________

Driving Background (experience, schools, etc.):___________________ 

_________________________________________________________  

Insurance Carrier:____________________________________________

Policy No:_________________________________________________

Policy Dates:_______________________________________________

Description of Liability Coverage:______________________________

Driver 3

Name:_____________________________________________________

Address:__________________________________________________

City/State:_________________________________________________

Zip:_________________________ email:________________________

Daytime phone:______________________fax:____________________

DOB:_____________________________________________________

Driver’s License No:___________________________State:__________

License Exp. Date:___________________________________________

NASA Membership No:_______________________________________

NASA Membership Exp. Date:_________________________________

Driving Background (experience, schools, etc.):___________________ 

_________________________________________________________  

Insurance Carrier:___________________________________________

Policy No:_________________________________________________

Policy Dates:_______________________________________________

Description of Liability Coverage:______________________________

 

Sponsor Information

 

Vehicle Information

Entrant Sponsor:_______________________________________________

Contact Individual:_____________________________________________

Sponsor Address:_____________________________________________

___________________________________________________________

Sponsor Telephone:___________________________________________

(attach separate sheet for each additional sponsor)
 

Vehicle class to be entered:____________________________________

Car Make:__________________________________________________

Model:___________________________Year:_____________________

Tire Size Front:______________________________________________

Tire Size Rear:______________________________________________

Unique Vehicle History (other events, etc):_______________________

_________________________________________________________

Vehicle License No:______________________State:_______________

Vehicle License Expiration Date:__________________________

 

Corporate Liability Insurance

Policy Holder:_____________________________________________

Holder Address:____________________________________________

Holder Contact Individual:____________________________

Insurance Carrier:_____________________________________________

Contact Ind. Phone No:_____________________________________

Policy No::________________________________________________

Policy Dates:______________________________________________

Limits of Liability Coverage:______________________________

 

I have read, understood and agree to comply with the 2013 One Lap of America event regulations. One Lap of America is a competitive longdistance endurance and, often times, high-speed driving event. It is myunderstanding that as participants, my crew and I will be required to drive great distances at normal highway speeds upon public roadways, compete against other entries in high-speed driving events on various race courses. As Team Captain, I have advised the members of my crew of the potential hazards involved.

With this knowledge, we feel that our driving experience and expertise qualify us to enter this event. The information as set forth in this application is true to the best of my knowledge, and I understand that if accepted, and it is determined that the information contained in this application is false or misleading, my team may be disqualified with noreimbursement of the entry fee. Non refundable entry fee: $3000 U.S. currency.

Team Captain, Signature:______________________________________

Print Name: _______________________________Date: ____________

 

 

 

 


You may print out the above entry form on your printer and submit it with the entry fee to Cannonball Circuits, LLC, 1415 State Road, Phoenixville PA 19460.