Please print the form below, fill it out and mail it to Short Track Management, LLC. 1725 West 16th Street, Merced CA 95348. You may pay by check or credit card, please make checks payable to Short Track Management, LLC. You may fax this form to 209-384-9595 if you are paying by credit card. Note, each member must sign a master waiver when they pick up their hard card at the race track.

Sale Price of license is $80.00 until February 3rd, 2012. ($95 after that date)

Members get $10 off the price of a pit pass, members compete for year end prizes, and championships as well.

2012 Short Track License Application

Name __________________________________________________________________

Address ________________________________________________________________

City ___________________________________

State______________________

Zip Code _____________________

Division / Class (list primary class only) _______________________________________

Car Number (first choice) ___________ (2nd choice) ____________

Check only one / Driver ($95.00) _____ Crew Member/Car Owner ($95.00) ____
(drivers that are owners check driver box)

Social Security number ____________________________ (drivers and owners only)

E-Mail address ___________________________________

Home Phone Number ______________________________

Cell Number _____________________________________

Alternate Number __________________________________

Emergency Contact: Name ___________________________________________

Phone Number ____________________________________

Payment method (must check one) Check____ Credit Card____ Cash ______



Below is for credit card users only;

Credit Card Information / Card Number ________________________________

EXP. Date ____________ Name ____________________________________

3 Digit Code __________ Date ______________________________________

Signature ________________________________________________________