CHAMPIONSHIP MUD RACING

2011 RACE SEASON

OFFICIAL SERIES APPLICATION

Class Registration is $20.00 for the first class
Each Additional Class Registration $10.00

(* indicates Required Field)

Pick the classes you wish to register for (For each class you register for you must enter in a make/model):

SWAMP CROSS CLASSES:
LITE 0 to 450cc -- MAKE/MODEL:

BOGGER 451cc to 750+cc (single cylinders only class) -- MAKE/MODEL:

PRO A 500 to 1000+cc Less than 53 inch wheelbase -- MAKE/MODEL:

PRO B 500 to 1000+cc More than 53 inch wheelbase -- MAKE/MODEL:

SUPER MODIFIED 0 to 1000+cc -- MAKE/MODEL:

RUV 0 to 1000+cc -- MAKE/MODEL:

WOMEN 0 to 1000+cc -- MAKE/MODEL:

MUD BOG YOUTH CLASSES:
Mud Bog Youth 1 0 - 125 Class -- MAKE/MODEL:

Mud Bog Youth 2 125 - 250 Class -- MAKE/MODEL:

Mud Bog Youth 3 251 - 450 Class -- MAKE/MODEL:

NOTE: *No refunds will be given if rider registers, but fails to compete in the series events.*

* CHECK HERE TO CONFIRM ACCEPTANCE OF RULES
The undersigned rider/entrant agrees to abide by all CMR rules, regulations, and decisions. This entry will not be accepted until all fees are received and processed and CMR Headquarters approves the entry.

Rider Information

*First Name: *Last Name:

*Telephone: ( ) (###)###-####

FAX: ( ) (###)###-####

CELL: ( ) (###)###-####

*E-MAIL Address:

*Mailing Address: (No PO Box's):

*City: *State: Select State... -- United States -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -- CANADA -- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory *Zip:

*Date Of Birth: MM/DD/YYYY

*(Driver must be over the age of 5 years old in order to race in youth, and the age 15 in order to race in adult classes - NO EXECPTIONS will be made. Proof of birth certificate will be required. If under 18, please obtain and sign a minor's release form)

Driver License # : State: Select State... -- United States -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -- CANADA -- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Exp. Date MM/DD/YYYY

*Emergency Contact Phone: ( ) (###)###-####

* CHECK HERE TO CONFIRM YOUR AGREEMENT TO RELEASE REUSE OF NAME, ETC.
In consideration of the awards of this event(s), the acceptance of this Entry by CMR, the vehicle owner and rider individually and jointly, agree and consent, that CMR, Promoter, and the assigns of either or both, may use their name(s), picture(s), likeness(es) or performance(s), of any them, in any way, medium or material for promoting, advertising, recording or reporting this event(s) before, during and after such event(s) including but not limited to television and radio broadcasts, film productions, video tape productions, video game productions and the like ("The Rights"), and do hereby relinquish all rights to CMR, Promoter, and the assigns for either or both for sales and other commercial projects.

*Required Field

Please send check or money order to the address below.

Championship Mud Racing Headquarters
122 Summit Lane
Bremen, GA 30110
Phone: 770-537-0152
Cell: 770-560-5182
Fax: 770-537-0151
www.championshipmudracing.com