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 group. KART NO. Choose only one class per group. KART NO. Group 1 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] _____ Group 2 ___ 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] _____ Group 3 _____ ___ 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 Group 4 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).