Intent to Compete Form - Jukasa Motor Speedway

Car & Driver Information

By submitting this Intent to Compete Form the Driver consents to the use, without charge, of their name and/or pictures of them and their race car, for promotional purposes.

Division & Race Date *

Super Stock (June 22)
Mini Stock (July 25)
Super Late Model (Aug. 31)
Late Model (Sept 28)

Car Number *

Car Make & Model *

Do You Have a Westhold Transponder? *

Yes
No ($25.00 rental fee, payable on race day)

Radio Frequency

Driver Name *

First

Middle

Last

Daytime Phone *

Cell Phone

Email *

Email

Confirm Email

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Primary Sponsor *

Emergency Contact *

Car Owner Information

required fields are indicated with an asterisk (*); please complete the rest of the fields if the owner is different than the driver

Purse Winnings Payable to: *

Owner
Driver
Other

Car Owner Name, if not Driver or Owner

Car Owner Name *

First

Middle

Last

Car Owner Daytime Phone

Car Owner Evening/Weekend Phone

Car Owner Email

Email

Confirm Email

Car Owner Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Good Faith Pledge *

The Applicant acknowledges the support and effort of racing fans, sponsors, the media, the tracks and the Promoter and agree they will compete on a best effort basis. The Applicant additionally agrees to notify the Promoter if they will not be competing in this event, realizing time is of the essence in this matter, and acknowledges the entry fee is non-refundable.

Form Completed By *

First

Middle

Last

Disclaimer

I UNDERSTAND AND AGREE JUKASA MOTOR SPEEDWAY MAY DECLINE OR WITHDRAW ANY ENTRY, WITHOUT CAUSE OR QUESTION.