7/30/2019 EDGE Driver Application.pdf

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2012 EDGE Competitor License ApplicationDriver Name: _____________________________________________ Car #:________________Mailing Address (House # or P.O. Box): _______________________________________________City:______________________________________ State: _____________ Zip: _____________Social Security#______________ Birthday: ______________ Home Phone:______________Email: ______________________________________ Home track: ________________________Class Participatg_______________________________ Shirt Size: __________________Sponsors:______________________________________________________________________

____________________________________________________________________________________________________________________________________________________________Fill out the following Information if different from the Driver:

Checks Payable To: _____________________________ S.S # or Tax ID #: ___________________Mailing Address: ______________________________________ Home Phone: ______________City:___________________________________ ___ State: _____________ Zip:_____________

Make checks payable to EDGE and mail to: P.O. Box 107, Middlebourne, WV 26149For credit c ard p urchases, please complete t he fol lowing:

Name On Card: ________________________________________________________________Card Number: _________________________________________________________________ExpirationDate:____________________________ CVC #: _____________ (Three Digit Number on Back of Card)

Wavier of LiabilityBy signing the registration form you are agreeing to abide by the rules, regulations, and penalties of theTri-State Modified Association. You also give TSMA and/or sponsors permission to use your name and/ or image without further compensation to you or your team for its use. You are giving your permissionto allow TSMA to use the information provided in any way TSMA deems necessary. This is a dangeroussport, you could be injured or killed. You are risking your life by participating in any fashion. By sign-ing you agree that you and/or family will not sue TSMA, officers, sponsors, and officials. The TSMA,and/or representatives are not responsible for any accident, loss, injury or death which may or may notoccur while attending, participating in, or a sanctioned event. The TSMA, officers, promoters, members,officials, sponsors, will not be held responsible or liable for injury or death. The rules which are used inthis sanction are intended only for the orderly conduct of a racing event, and should not be interpretedor construed to warrant and/or guarantee safety in any way.

DRIVERS SIGNATURE _____________________________________ Date _________Entering false information on this form is a Federal offense and will cause explusion fromTSMA, and legal action will be taken according to Federal Law

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ADDRE

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P H O NE

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[ ] $ 75 Modified [ ] $ 50 Crate [ ] $ 40 Hot mod [ ] $15 Temp. LicenseIf Temporary License, What Division: _______________________________