| 2025 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 610 563-5603 Please include a phone number with all written requests for information. Cannonball Circuits, LLC 2017 West Strasburg Road, West Bradford, PA 19320
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| 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:____________________________________________
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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:____________________________________ Vehicle License Expiration Date:__________________________
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| Corporate Liability Insurance | |
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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 2024 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: $4000 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, 2017 West Strasburg Road, West Bradford, PA 19320.