INTERNATIONAL 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/ [ ] [ ] Motorcycle

CLASS / CATEGORY 400 Meter Times 200 Meter Times [ ] [ ] Top Bike [ ] Pro Slammer [ ] * 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