MODS License Form

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PASS MOD DIVISION
2005 TEAM LICENSE and
NUMBER REGISTRATION FORM
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DRIVER NAME: ______________________________________DATE:____________________

ADDRESS:____________________________________________________________________

_____________________________________________________________________________

PHONE: DAY____________________________ EVENING _____________________________

DATE OF BIRTH: ___________________ SOCIAL SECURITY # ________________________

OWNER NAME: ________________________________________________________________

ADDRESS:_____________________________________________________________________

_______________________________________________________________________________

PHONE: DAY____________________________ EVENING _____________________________

DATE OF BIRTH: __________________ SOCIAL SECURITY # _________________________

CAR NUMBER REQUESTED: ___________

MAKE PURSE CHECK PAYABLE TO: ______________________________________________

All PASS Mods must display the PASS windshield logo on the leading edge of the roof.

Please check decal color desired: ______White ______Yellow ______Orange

PASS Use Only Date Received _______________ By: __________________________

Check #/Cash ______________________________

2005 License: $50 US Dollars (only one per car is needed)

Please make your check payable to: Pro All Stars Racing, Inc 195 Lakehouse Road, Naples, ME 04055

There are no entry fees for PASS Mod race events. However, a PASS License is required