OTC 2005 Entrant Registration Form  

Please type in the information into the following text boxes.  Upon completion, print this form (CTRL+P), sign it and mail it in with your entry fee:
ENTERED VEHICLE INFORMATION
Year, Make, & Model (example: 2001 Dodge Viper):
Division (please consult the rules):
Class (please consult the rules):
Car Number (specify 3 choices, first come first serve):
DRIVER INFORMATION
Driver #1 
Name of Driver One/Team Captain:
Mailing Address of Driver One/Team Captain:
Phone Number:
Email Address:
Track Experience or Competition Licenses Held 
NASA Member Number:
Emergency Contact: (name and phone number)
Driver #2
Name of Driver Two:
Track Experience or Competition Licenses Held
NASA Member Number:
Emergency Contact: (name and phone number)
Driver #3 (if applicable, please add $100)
Name of Driver Two:
Track Experience (list motorsports clubs, driving schools, and other relevant track experience)
NASA Member Number:
Emergency Contact: (name and phone number)
Driver #4 (if applicable, please add $100)
Name of Driver Two:
Track Experience (list motorsports clubs, driving schools, and other relevant track experience)
NASA Member Number:
Emergency Contact: (name and phone number)
CREDIT CARD INFORMATION:
Credit Card Type:
Credit Card Number
Credit Card Expiration Date
Name on Credit Card
ENTRANT AGREEMENT
I have read, understood and agree to comply with the regulations of the 2005 Open Track Challenge.  I understand that as participants, my crew and I will be required to drive great distances at normal highway speeds upon public roadways, compete against other entries in high-speed driving events on various race courses. As Team Captain, I have advised the members of my crew of the potential hazards involved.

With this knowledge, we feel that our driving experience and expertise qualify us to enter this event. The information as set forth in this application is true to the best of my knowledge, and I understand that if accepted, and it is determined that the information contained in this application is false or misleading, my team may be disqualified without reimbursement of the entry fee.

By submitting this form I also understand the stated refund policy. I understand that this event is governed by the Club Codes and Regulations and in cases of dispute the decision of the Event Chairman is final. I hereby release Zen Five Productions, L.L.C., and the National Auto Sport Association, its officers, members, workers, and sponsors, and any of the officials from any liability for damage to my car or equipment, theft of the same, and from any injury to me or anyone accompanying me whether adult or minor, which may result from my presence at this event as a spectator, worker, or participant. I also understand that I, as a driver, am responsible for the conduct and behavior of those accompanying me to this event such as crew, mechanics, and friends. I have been examined by a physician and am physically fit to participate in a high stress and physically demanding sporting event. I am not suffering from any diseases or disorders or under any drugs, legal or illegal, that would affect my performance at this event. I understand that this activity is not recommended for pregnant women.
Name of the Team Captain
Signature of Team Captain Date
 

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