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Car # ______________________
Body - ( Year/ Make
)_______________________________________________________________
Chassis: _______________________________
Motor: _____________________________
Name:_____________________________________________________________________________
Address:__________________________________________________________________________
City:___________________________________________ State:______
Zip:___________________
Home Phone:_____________________________ Work
Phone:____________________________
Cell Phone:_____________________________
E-Mail:____________________________
MEMBERSHIP DUES $15.00 - CAR REGISTRATION $25.00
Anyone can run one time without joining the club.
After that they must meet club rules and pay club dues.
CAR REGISTRATION: $25.00 to be paid by first race of the season.
( Car gets one Membership card with Registration )
Associate Membership: $15.00
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Name:____________________________________________
Address:__________________________________________
City:___________________________________________
State:______ Zip:___________________
Name:_____________________________________________
Address:__________________________________________
City:___________________________________________
State:______ Zip:___________________
Name:_____________________________________________
Address:__________________________________________
City:___________________________________________
State:______ Zip:___________________
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Please Make Checks Payable To:
Ed Stevens /
NVDM Racing
Club
1101 RT. 211
West
Middletown,
NY. 10940
Information On Club Activities Contact:
Phone
845 386
3484
For Taped Message
845 - 294 - 3204
www.vintagedirtmodified.com
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