Wagner SPEEDWAY  

P.O. Box 787

Wagner, SD 57380

2013 Car & Number Registration

Fee $25.00 Per Car (Check must be mailed with this form)

Driver

First Name:___________________________________________ Middle Initial: _____________

Last Name:______________________________ Address:______________________________________

Home Phone: ___________________________   City :________________________________________

State:______________________ Zip:_______________________ DOB:_______________________

Email Address:______________________________________________

Social Security # or TAX ID #______________________________

Car #________________ Class:___________________ Points Fund Paid:______________

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Car Owner

First Name:___________________________________________ Middle Initial: _____________

Last Name:________________________________ Address:____________________________________

Home Phone: ___________________________   City :________________________________________

State:______________________ Zip:_______________________ DOB:_______________________

Email Address:______________________________________________

Social Security # or TAX ID #______________________________

Sponsors:_____________________________________________________________________________

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Accomplishments:______________________________________________________________________

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