2010 Pit License Application & Car Number Registration

This pit license application does not guarantee your car number!

(Numbers will be assigned on a first come, first serve basis. Please provide a 1st and 2nd choice for car number. - NO DUPLICATE NUMBERS WILL BE PERMITTED!!!)
Applicant Name__________________________________________________________

Social Security #_____________________ **Date of Birth:_____________________

**Applicants under 18 years of age must include a notarized release signed by Parent or Legal Guardian, giving permission to participate in racing activities. No one under the age of 12 will be allowed in Pit Area.

Street Address____________________________________________________________

City_______________________ State________________ Zip Code_____________

Phone # __________________ Emergency Contact #______________________


Car# 1st choice______   2nd choice______ Cars painted identical or back up cars, must be numbered differently-NO DUCT TAPE NUMBERS
(Check one): Driver_____ Owner_____ Crew Member_____

Pit License Fee: $75.00 ($10.00 replacement fee will be charged for lost licenses)

I, the undersigned, have read, understand, and agree to obey and be bound by all the rules, regulations and requirements set forth by Mountain Speedway. I will make no claim nor file any action/actions against Mountain Speedway. I agree to refrain from any types of public demonstrations, public picketing or vocal airing of grievances in public on the day of scheduled race meet at Mountain Speedway. All those who fail to adhere to the above will be dealt with according to the law and face immediate forfeiture of their Mountain Speedway Pit License. Mountain Speedway Pit License shall be considered a privilege. Management reserves the right to refuse any application and return fee without showing cause.
Date___________   Print:_________________________   Sign:________________________________

Mail Form with Payment To: Make Check Payable To: Mountain Speedway

Mountain Speedway
627 Can-Do Expressway
Hazle Twp., PA 18202