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2017 Ihra / Australian Membership, License & Number

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2017 Ihra / Australian Membership, License & Number INTERNATIONAL HOT ROD ASSOCIATION 1555 Palm Beach Lakes Blvd, Suite 1105 West Palm Beach, Florida 33401 Phone: 561-337-3015 Fax: 561-562 -4020 [email protected] 2017 IHRA / AUSTRALIAN MEMBERSHIP, LICENSE & NUMBER (PAGE 1) THIS FORM AND THE COMPETITION LICENSE FORM MUST ACCOMPANY ANY NEW APPLICATION MEMBERSHIP & COMPETITION LICENSE: (Includes Rule Book, Decals, Membership Card & Car Numbers) 1) SELECT TYPE OF APPLICATION: [ ] New Application [ ] Renewal 2) SELECT LENGTH OF MEMBERSHIP: [ ] $90.00 one year [ ] $160.00 two years [ ] $235.00 three years 3) SELECT CLASSES AND CAR NUMBERS: (NOTE – IF YOU DO NOT HOLD A CURRENT ANDRA LICENSE AND CAR NUMBER, YOUR CAR NUMBER WILL BE 6000 OR HIGHER) CLASS _________________________ PERMANENT CAR NUMBER __________________ CLASS _________________________ PERMANENT CAR NUMBER __________________ CLASS _________________________ PERMANENT CAR NUMBER __________________ NOTE: ALL FUNDS IN U.S. DOLLARS GENERAL MEMBERSHIP: Includes Rule Book, Decals and Membership Card – NO Competition License $80.00 one year ______ $140.00 two years ______ $205.00 three years ______ NOTE: ALL FUNDS IN U.S. DOLLARS ASSOCIATE MEMBERSHIP: Does not include Rule Book. (Household must have a current full member at the same address) Subtract $10.00 per year __________ Full Member Membership # ________________ Expiration Date ______________ Name __________________________________________E-MAIL ADDRESS___________________________ Address ___________________________________________________________________________________________ City ____________________________________________ State __________________ Post Code ________________ I am also an ANDRA [ ] Yes [ ] No (If yes, please include copy of your ANDRA license with these forms PAYMENT METHOD [ ] Cash [ ] Check [ ] Money Order TOTAL AMOUNT PAID [ ] Visa [ ] M/C [ ] Discover [ ] AmEx $ Credit Card # ____________________________ Security Code ____ Exp.____ - ____ MONTH YEAR ALL FUNDS IN U.S. DOLLARS By signing this application, I certify that I have read and agree to abide by all the rules, regulations and agreements of the IHRA rulebook and related publications. I understand that additions and amendments to the IHRA rulebook will appear SIGNATURE:______________________________________ online. (Effective 1/1/17) INTERNATIONAL HOT ROD ASSOCIATION 1555 Palm Beach Lakes Blvd, Suite 1105 West Palm Beach, Florida 33401 Phone: 561-337-3015 Fax: 561-562-4020 [email protected] 2017 IHRA AUSTRALIA COMPETITION LICENSE FORM (PAGE 2) Each “NEW” applicant must enclose a photocopy of their state issued driver’s license with these forms. NOTE: a learner’s permit is not acceptable This Section To Be Filled Out By Applicant Note: (Page 1 is also required) O New O Renewal O Upgrade O ANDRA Transfer (Copy of current ANDRA license required) Car#______________ Class Applied For_____________________ Home Track _____________________________________ Name__________________________________________________________ Date of Birth __________________________ Address ________________________________________________________ Email ___________________________________ City _______________________________________ State _______________ Post Code __________ [ ] Full Bodied Car [ ] Altered/Funny Car [ ] Dragster [ ] Motorcycle CLASS / CATEGORY 400 Meter Times 200 Meter Times [ ] Top Fuel [ ] Top Bike [ ] Pro Slammer [ ] Pro Stock * Physical/Medical * Physical/Medical [ ] Exhibition [ ] Pro Alcohol [ ] Pro Bike Required Required [ ] Competition [ ] Supercharged Outlaws [ ] Super Stock * Physical/Medical * Physical/Medical [ ] Competition Bike [ ] Top Sportsman [ ] Super Compact Required Required [ ] Modified [ ] Super Sedan [ ] Pro Radial t 0 – 9:99 – Car 0 to 6.39 – Car [ ] Modified Bike [ ] Super Gas t 0 – 9:49 – Bike 0 to 6.14 - Bike [ ] Super Street 10.00- Slower - Car 6.40 - Slower - Car 9.50 - Slower - Bike 6.15 - Slower - Bike [ ] Junior Dragster Copy of birth certificate required for all NEW N/A 8:00 – 15:00 Junior Dragster applications I, the undersigned, do hereby understand the full provisions of the competitor’s license issued to me by the IHRA, and accept the responsibility of operating my vehicle in a safe, sportsmanlike manner, and in accordance with all rules and regulations issued by the IHRA, and further, will accept any ruling by the IHRA suspending my driver’s license rights in the event that I fail to strictly follow all of my responsibilities. I agree to abide by all rules, regulations and requirements contained in the IHRA Australian rulebook, related publications and any amendments issued by the IHRA subsequent to the issuance of my license. I hereby agree and acknowledge that the Release and Waiver of Liability, Assumption of Risk, Indemnity and Rights Agreement which I have signed extends to all acts of negligence or other wrongdoing by the Releases, and is intended to be as broad and inclusive as is permitted under applicable law, and that if any portion thereof is held invalid, it is agreed that the balance shall remain in full force and effect. Date: ______________________ Driver’s Signature ____________________________________________________________ This Section Is To Be Filled Out By Track/IHRA Official and Licensed IHRA Competitors Only (Current IHRA or ANDRA License # ___________ Code ________) If ANDRA transfer, passes not required but copy of ANDRA license required. (If passes are made on 200meter track, you will receive a license restricted to 200 meters) Facility Name _________________________________________________________________________ O 400 meters O 200 meters 1. 100 meter E.T. _________ MPH _________ Track Official Witness ____________________________________ 2. Half Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 3. Half Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 4. Full Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ 5. Full Pass E.T. _________ MPH _________ Track Official Witness ____________________________________ LICENSED DRIVER SIGNATURES REQUIRED FOR CLASS A PRO DRIVERS ONLY Date IHRA/ANDRA Licensed Driver/Rider IHRA Member # Signature _________ ______________________________ _____________ ___________________________________ _________ ______________________________ _____________ ___________________________________ _________ ______________________________ _____________ ___________________________________ Date Approved __________________ Approved By ________________________________________________________ 1/1/17 IHRA OR TRACK OFFICIAL ONLY .
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