Region12 ENTRY BLANK

Required * A Separate Entry is Required for Each Class

Driver

Owner Same as Driver

Rider/Co-Driver


Contact


Boat/Driver qualifications for Kilos or Championship Races

(As Required by Division Rules)


Personal Info


Category


This Entry Blank MUST be filled in with ALL DETAILS and filed with the local Race Committee in accordance with APBA General Racing Rules 3, 4, and 5. Owners and Drivers must report immediately to Registration Headquarters upon arrival at race, present current membership card and have entry checked. Drivers failing to do so and starting in race will not be scored. Entry will not be accepted unless properly signed.

AGREEMENT OF RELEASE

I represent by my signature below that my Agreement of Release is on file with my current membership, and my membership card number is as shown above. I further represent, if I do not possess a current membership card, that I have signed the current Agreement of Release attached with my membership application previously mailed to National Headquarters, or submitted to Registration Officials at the above regatta. In consideration of their promotional efforts on behalf of the sport, I hereby assign all commercial communication and broadcast rights to the American Power Boat Association and do declare them as my lawful agents and representatives regarding such rights. I, the undersigned member participating in events sanctioned by APBA, agree that APBA and its assigns may use my name and picture and pictures of my race boat, or any of them, in any way, medium, or, material for promoting, advertising, recording, reporting any APBA sanctioned events before, during and after such event and do hereby relinquish all rights hereto for these purposes.


Signed (Driver):

(LS.)

Signed (Owner):

(LS.)

Signed (Rider/Co-Driver):

(LS.)

Signed (Guardian/Parent for):

Name

If under 18:

(LS.)

MUST BE SIGNED AT RACE OR MAILED WITH ALL SIGNATURES

This form MUST be submitted by the date required on the official Circular.