| First name: |  | 
		
			| Last Name: |  | 
		
			| Email Address: |  | 
		
			| Phone Number | (xxx) xxx-xxxx | 
		
			| Address |  | 
		
			| City, State and Zip |  | 
		
			| Are you a member of a Car Club? |  Yes  | 
		
			| If Yes, name of your Car Club: |  | 
		
			| Make of vehicle being entered |  | 
		
			| Model of vehicle being entered |  | 
		
			| Year of vehicle being entered |  | 
		
			| Don't forget to select the "Buy Now" link on the following page to pay your entry fee. |  | 
		
			|  |  |