7/29/2019 EDGE Renegade Application

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2013 Renegade of Dirt Modified Tour Competitor License Application

Please Read Over Carefully and Fill Out With the Correct Info as Requested:

Driver Name: _______________________________________________ Car #:________________

Mailing Address (House # or P.O. Box): _________________________________________________

City: ______________________________________ State: _____________ Zip: _______________

Social Security #: __________________ Birthday: ______________ Home Phone:______________

Email: ________________________________________ Home track: ________________________

Chassis / Engine Builder : ____________________________________ 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 26149

[ ] Renegade of Dirt Modified Tour / Championship Participant[ ] Renegade of Dirt Modified Tour / Rookie of the Year Contender

Entitles drivers to full benefits, point fund, contingencies, bonus programs, and increased exposure for your race team

and sponsors through cutting edge Renegades of Dirt Modified Tour marketing platforms.

(Advertising and Promotion Release)EDGE Renegades of Dirt Modified Tour, its duly authorized agent and assigns, is hereby granted the right of

uses of the applicant's name, likeness and photographs of the applicant or the applicant's car(s), taken during the event, in any medium or material,

for promoting, advertising, recording, or reporting any EDGE Renegades of Dirt Modified Tour sanctioned event(s), including but not limited to

television, and radio broadcasts, film production, video tape productions, and do hereby relinquish all rights thereto for these purposes.

Sign Here : X______________________________________________ Date : X_____________

License Number #: _____________________________ Competitor Name: ____________________________________

Paid with: [ ]cash [ ]check --- Check #: ____________________________

Competitor Hometown: __________________________________________ State: ____________________________

Please Do Not Fill Out / EDGE Official Purposes Only ~ Please Do Not Fill Out / EDGE Official Purposes Only