TRCKS
PRO STOCK DIESEL 4X4 TRUCKS
2011 PROGRAM
SOUTH BEND CLUTCH CONTINGENCY
DATE OF PULL: ___________________________________________________________________
LOCATION OF PULL: ______________________________________________________________
MAKE CHECK PAYABLE TO: ______________________________________________________
ADDRESS OF OWNER: ___________________________________________________________
CITY, STATE, ZIP: ________________________________________________________________
SOCIAL SECURITY NUMBER or TAX I.D.: __________________________________________
FINISH POSITION AT EVENT (circle one of the following):
FIRST = $ 150.00 SECOND = $100.00 THIRD= $50.00
I REALIZE THE PROGRAM HAS A MAXIMUM YEARLY PAY-OUT OF $3000.00 BY MY SIGNATURE, I CERTIFY THAT MY TRUCK HAS BEEN ‘PRE-CERTIFIED’ BY A USA-EAST OFFICIAL and THAT NO CHANGES HAVE BEEN MADE SINCE THAT TIME THAT WOULD AFFECT THIS CONTINGENCY: SIGNATURE OF OWNER/DRIVER: ______________________________________________________ |
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RETURN THIS COMPLETED AND SIGNED FORM TO:
SOUTH BEND CLUTCH
709 West Jefferson Boulevard
Mishawaka, IN 46545
(all payments will be made directly by South Bend Clutch)
