MKM Racer S Club Membership Application

US Autobahn Series (USAS) Membership Application

Please fill out the membership application below, and indicate which race or races you are interested in attending. Upon receipt, we will immediately forward you a membership card and the entry forms and race materials you will need for the races you have selected.

Bonneville 100 _____ Pony Express 130 ______July 13-16, 2006 August 24 - 27, 2006

Do you need a race pre-run video? Yes______No______

MEMBERSHIP INFORMATION As per MKM Racing Promotion’s agreement with the Nevada D.O.T, all persons in a vehicle competing in the event must be paid members of USAS. Please check the appropriate membership box and fill in the corresponding section.  Individual Membership ($50 annually)  2nd Individual Membership ($50 annually) (Non-Family Navigator for listed driver) Name: ______Tel. #: ______Name: ______Tel. #: ______Address: ______Address: ______City: ______State: ____ Zip: ______City: ______State: ____ Zip: ______

 Family Membership ($75 annually) Driver or Navigator (Circle One)  2nd Family Member Name: ______Tel. #: ______Name: ______Tel. #: ______Address: ______Address: Lifetime memberships are also available for $200. Lifetime members receive preference on grid reservations, and a permanent car number exclusive to them. Car numbers are available on a first-come, first-served basis. Immediate family members are also included in the membership. To become a lifetime member, check the box below and fill out the information section below instead of the one above.

 Lifetime Membership (one-time payment of $200)  Car # desired______2nd choice______Name: ______Tel. # ______Address: ______City: ______State: ____ Zip: ______Email address: ______

METHOD OF PAYMENT:  Check  Money Order  Visa  Mastercard

Credit Card # ______Exp. ______

PRINT NAME______SIGNATURE______

For Information Call, Fax, Write or Email 8170 S. Eastern, Ste # 4-611 Las Vegas, NV 89123 Voice: 702-614-6108 Fax: 702-614-6109 Email: [email protected] www.openroadracing.com For Information Call, Fax, Write or Email PMB 611 8170 S. Eastern, Ste #4 Las Vegas, NV 89123 Voice: 702-614-6108 Fax: 702-614-6109 Email: [email protected] Visit us on the World Wide Web at www.openroadracing.com