2019 ICP Cup Road Race Series OFFICIAL RACE REGISTRATION FORM

CHECK ___ May 11, 2019 PKA – Oregon Raceway Park, Grass Valley, OR DATE: ___ July 20, 2019 NWRR – Oregon Raceway Park, Grass Valley, OR ___ September 7, 2019 NWRR – Spokane County Raceway, Spokane, WA ___ 10/12/2019 PKA – Portland International Raceway, Portland, OR

Name: ______Date of Birth: ______Age: ______Address: ______Phone: ______City/State/Zip: ______E-Mail Address: ______Member Kart Club: ______Transponder No. ______

Choose only one class per . KART NO. Choose only one class per group. KART NO. Group 5 ___ Honda CR 125/99cyl [400] ______NW Unlimited / Super Kart [see rules**] ______125cc Open Shifter Limited Heavy [420] ______NW 125cc Open Shifter [400] ______Spec Honda CR 125/99cyl [385] ______NW Honda CR 125/99cyl [400] ______Unlimited / Super Kart [see rules**] ______NW Honda CR 125/99cyl Heavy [440] _____ ___ NW Spec Honda CR 125/99cyl [385] ______TaG Endruo [see rules**] ______NW Junior Shifter [340] ______Honda CBR 250 Formula R [490] ______NW Formula Experimental (formerly ICE) ______Yamaha KT100S Heavy[400] ______Group 6 ___ TaG Light [see rules**] ______80cc-100cc Open [see rules**] ______Briggs World Formula [390] ______NW Briggs World Formula [390] ______TaG Junior [330] ______NW Honda CBR 250 Formula R [490] _____ ______Formula Experimental (formerly ICE) ______I have a starting grid position based on the ___ 125cc Open Shifter Limited [400] _____ date and time my entry was received by ___ Honda CR 125/99cyl Heavy [440] _____ PKA. ___ Junior Shifter [340] ______I have a 2018 NW Gold Cup Road Race Champion starting grid position (List ___ TaG Heavy [see rules**] _____ class(es))*: ___ Honda CR 80 Enduro [410] ______125cc-150cc Open [see rules**] _____ * - To be verified by NWKA records ___ NW TaG Junior [330] _____ ** - Weight depends on engine/kart package. ___ Junior Briggs 4-Cycle [310/330] _____ See NWKA ICP Cup Rulebook. ___ Yamaha KT100S Light [370] _____

Emergency Contact and Phone Number: ______At Track? Yes No

Item/Amount Quantity Total First Two Entries GOLD CUP MEMBER $ 225.00 First Two Entries NON GOLD CUP MEMBER $ 300.00 Each Additional Entry $ 25.00 JR Entry (all junior classes per class) $ 85.00 Novice Entry – One Race Entry $ 100.00 Novice Entry – First Two Race Entries $ 170.00 Buddy Drive (must purchase pit pass) $ 25.00 Camping Fee $ 30.00 Non-Participant Pass for Entire Event ages 4 and up $ 12.00 Pit passes required for everyone in your pit, failure to comply will result in driver DQ. Transponder Rental:Very Limited Supply $ 25.00 GRAND TOTAL:

ENTRANT SIGNATURE: ______DATE: ______

Mail To: NW Gold Cup RR c/o Ann Harlow 13115-A NW 11th PL Vancouver, WA 98685 Make check payable to appropriate club hosting the event (PKA or NWRR as above)