Event Date ___________________
 

Entrant	Car
Name	Make
PCA#	Model
Day Phone#	Year
Street	Color
City	Engine Displacement
E-mail Address	Street Tires?                UTQG Tread Wear Rating
Emergency Contact	Modified?                     A Points           B Points          C Points
Emergency Phone #	Class
	Developing Driver?
Need Instructor?	Car # (if known)

Entry Fees per Driver	Full Year	Per Event	Non-PCA Member
Saturday Events	$150	$25	$30
Sunday Events	$75	$15	$20

I certify that there have been no changes and/or modifications since the last event and that the above vehicle is structurally sound and safe.                      Signature ______________________________________   Date __________

Print out this form, fill it out, and send to Wendy Shoffit, Event Registrar, 1112 Santa Fe Trail, Irving, TX 75063
Please make checks payable to "Maverick Region-PCA" or "MR-PCA".

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