VIRGINIA CITY HILLCLIMB
June 3rd-4th, 2000
REGISTRATION FORM
DRIVER ONE DRIVER TWO

NAME: _________________________________ NAME: ____________________________________

DATE OF BIRTH:________________________ DATE OF BIRTH:___________________________

ADDRESS:______________________________ ADDRESS:_________________________________

CITY:__________________________________ CITY:______________________________________

STATE:____________________ZIP:_________ STATE:_______________________ZIP:__________

DRIVER'S LICENSE #____________________ DRIVER'S LICENSE #________________________

STATE ISSUED:__________________________ STATE ISSUED:_____________________________

EMERGENCY CONTACT:_________________________________ PHONE #____________________

VEHICLE INFORMATION

MAKE:__________________________________ MODEL:____________________________________
YEAR:__________________________________ COLOR:____________________________________
CAR # CHOICE 1ST_______2ND______3RD NUMBER______ (ENTRANT SUPPLIES)
Following is information required by Nevada Department of Transportation.
VIN # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

LICENSE PLATE NUMBER/STATE:______________________________________________________
INSURANCE COMPANY:_____________________________POLICYNUMBER:_____________________________

Mail to: Entry Fees:
Brian Hunt
Virginia City Hillclimb Assoc. One Driver Car $249.00/$199.00* ___________
817 Travis DR.
Carson City, NV 89701 Two Driver Car $449.00/$389.00* ___________
(775) 355-8093 FAX (775) 831-1745
Or email to: VCHAReno@AOL.COM TOTAL $___________
* Special rate for entries received by 5/3/2000
PAY BY CREDIT CARD: Visa/MasterCard or Discover circle one:

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Expiration ___ ___ / ___ ___

Signature:_________________________________