REGISTRATION FORM - MUST BE IN NO LATER THAN 1:00 pm JUNE 16, 2005 FOR THE JUNE 18 RACE AND 1:00 PM JULY 25, 2005 FOR THE JULY 27 RACE AND 1:00 PM SEPTEMBER 1, 2005 FOR THE SEPTEMBER 3 RACE.
Name of Driver____________________________________
Phone Number__________________Make & Model of Car_________________
Age of Driver____Male____Female_____Car number assignment____________
Entry fee Paid by Cash____________Check______________
Registration for JUNE 21 RACE______________Remit $10.00
Registration for JULY 23 RACE______________Remit $10.00
Registration for Sept. 3 Race______________Remit $10.00
Please check which race you are entering
Total enclosed_____________________
Address___________________________
City______________________________
State_____________Zip_____________
Return to: Peggy Groves
Lyon County Fair Assn
1206 Buchanan Ave
Larchwood, IA 51241