Lee County Speedway



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This form MUST be completed, signed and all fees paid in order to receive prize money. PLEASE PRINT CLEARLY!

OFFICE USE ONLY

Rcd. By _________ Date Paid _________ Amount _________ Cash CC Check # ______ IMCA oð

DRIVER S Nο

DRIVER’S Name ________________________________________________ Car# _________________

DRIVER’S Social Security # ______________________________________ Class _________________

DRIVER’S Address _____________________________________________________________________

City _______________________________________ State _________________ Zip Code ______________

Phone # ____________________________ e-mail address ______________________________________

Cell Phone # _________________________ ο Check this box to receive Text Message Updates (such as Rain outs)

PRIZE MONEY AUTHORIZATION – If other than driver

Person or Business that Federal 1099 should go to if other than above – If same as driver you may leave blank.

Required by Federal Government to avoid a 28% withholding of prize money.

SS# or Federal ID # _________________________________________________ (must match check’s payable)

Make Checks Payable to ____________________________________________________________

Address _______________________________________________________________________________

City ____________________________________ State _________________ Zip Code _________________

Phone # ____________________________ e-mail address ______________________________________

Cell Phone # _________________________ ο Check this box to receive Text Message Updates (such as Rain outs)

AGREEMENT

CONTRACT: I am an independent contractor assuming all responsibility for money received as a result of my activities including, without eliminating, income tax, FICA, workman’s compensation and withholding taxes. I am not an employee, servant or agent of Lee County Speedway, Inc.

BENEFITS: I agree that myself, executors, and assigns will be entitled only to the benefits of the Competitor Accident Policy procured by Lee County Speedway, Inc. for accidental injuries which are the result of external, violent, and visible means sustained in Lee County Speedway, Inc. events. The foregoing shall constitute the limit of liability of Lee County Speedway, Inc. for such injuries occurring to me in any Lee County Speedway, Inc. event provided proper notification is given.

COMPLIANCE: The undersigned agrees to abide by all rules and regulations of Lee County Speedway, Inc. now published or hereinafter modified. In consideration of the acceptance by Lee County Speedway, Inc. of this agreement the undersigned recognizes his obligation to the public and Lee County Speedway, Inc. which posts the prize money and conducts the events, and agrees to compete in all events when qualified if humanly possible.

BREACH AND DAMAGE: In the event the undersigned breaches this agreement he shall be liable for actual liquidated damages sustained by Lee County Speedway, Inc.

OWNERSHIP: If owner of a registered car, I certify I have good and marketable title to said vehicle or any part thereof in the event the same is claimed pursuant the rules.

ADVERTISING RELEASE: The undersigned consents to the use of his name, pictures of himself, and his car for publicity, and relinquishes any rights to photos taken in connection with events and consents to the publication or sale of such photos as Lee County Speedway, Inc. so desires.

ARBITRATION: Any controversy or claim arising out of or relating to this agreement including any alleged breach, shall be settled in accordance with the rules and regulations of the Lee County Speedway, Inc. and the undersigned agrees to accept the decision rendered by this process.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. I AGREE TO ABIDE BY ALL TERMS OF THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES OF THE LEE COUNTY SPEEDWAY, INC.

Driver __________________________________________ Date _______________________

Owner __________________________________________ Date _______________________

3535 Main Street, Keokuk, IA 52632

(319) 795-8866 or (641) 521-0330

Office Use Only

Car # ________

Class ________

Pkg # ________



Track Membership $25

IMCA Modified, IMCA Stock Car, IMCA SportMod,

IMCA Hobby Stock, IMCA Sport Compact

Reserved Parking Available - $50

For Office Use

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