July 9-10, 2010 - Summit Point

Midnight Moonshine Run 6 Hour Endurance Race Entry Form - $450 Per Car

TEAM INFORMATION

Team Name:	Team Web Site:	Team Sponsors:
Your Name (Entrant):	Daytime Phone Number:	Evening Phone Number:
Your E-mail Address:	Reenter Your E-mail Address:
Address Line 1:	Address Line 2:
City:	State:	Zipcode:

VEHICLE INFORMATION

Car numbers will be assigned based on the date and time your entry form is received.
Prep rules for the USERA classes will be defined by the 2010 USERA Rules.
Prep rules for the SCCA classes will be defined by the 2010 GCR classification rules.
NOTE: THIS EVENT IS *NOT* SANCTIONED BY SCCA.

Select Your Class
	USERA American Touring Car (ATCC) Includes Most ITE, ITR, T2 and T3 Cars (Rules) USERA Spec Racer Challenge (SRF) (Rules) USERA Spec Miata (SM) (Rules)	SCCA ITA SCCA ITB SCCA ITC SCCA ITS	SCCA ITE SCCA ITO SCCA IT7 SCCA AS SCCA SSM	SCCA SSB SCCA SSC SCCA T1

Car Color:	1st Car Number Choice:	2nd Car Number Choice:	3rd Car Number Choice:	Transponder Number:
Make/Model:

DRIVER AND CREW INFORMATION

All drivers and crew must be current members of USERA. USERA membership is free, and participants will be required to sign the USERA and any other track insurance waivers at the event registration window. USERA Annual Hard Cards will be recognized for the event, but you may still be required to sign both the track and other waivers.

When you supply each of your team member's e-mail addresses, we will send them a notice that you have added them to the team with a reminder that they must have a current USERA membership for this event.

Driver 1:	E-mail Address:	Driver 2:	E-mail Address:
Driver 3:	E-mail Address:	Driver 4:	E-mail Address:
Crew 1:	E-mail Address:	Crew 2:	E-mail Address:
Crew 3:	E-mail Address:	Crew 4:	E-mail Address:
Crew 5:	E-mail Address:	Crew 6:	E-mail Address:

== ACKNOWLEDGEMENT AND DISCLAIMERS ==

1.	Car numbers will be assigned based on the date and time your entry form is received.

2.	Entrant agrees that this entry constitutes an agreement to take part in the EVENT per the USERA Sporting Regulations, Supplementary Rules and any posted bulletins for the Event. Entrant agrees to abide by all series and track rules governing the EVENT.

3.	Drivers must have a valid competition license as specified in the USERA Sporting Regulations.

4.	One entry form is required per car and the Entry is not considered complete until the Entry Fee Payment has been paid. All checks must be made payable to "USERA, Inc.".

In consideration for being permitted to participate in the Event, Entrant and all Entrant team members agree to permit Event promoters/organizers the use of their name, voice and/or likeness, and images of the team members and team cars, for news, publicity, and feature use including radio, television, internet, motion picture film, newspapers, magazines and any and all other media as deemed prudent to advertise, market and other for the purposes of trade related to the promoters.

6.	A $100 late fee will be charged for entries received or paid after June 25, 2010. A $100 non-refundable processing fee will be retained in the event of withdrawal from the Event for any reason.

IF OFFERED, ANY PRIZE MONEY OR OTHER AWARDS WILL BE PAID OR PROVIDED ONLY TO THE ENTRANT DESIGNATED ON THIS EVENT ENTRY FORM. A W-9 (OR W-8) MUST BE ON FILE BEFORE ANY CASH AWARDS CAN BE PAID. ANY PRIZE MONEY OR OTHER AWARDS THAT REMAIN UNCLAIMED NINETY (90) DAYS AFTER THE DATE OF THE EVENT WILL BE FORFEITED.

I have read the acknowledgement and disclaimers above and I FULLY AGREE to their terms and conditions.

By pressing SUBMIT, I acknowledge that I am a representative of the above named team, and hereby register the race vehicle on behalf of the team. If paying by credit card, I authorize USERA, Inc. to charge my event entry fees to the credit card information I will fax to seperately using the Credit Card Authorization Form.