The Tarheels Revisited and Runaway Mine Train Entry Form

July 20 and 21, 2002 at Salisbury NC

Driver______________________________ Navigator______________________________

Address_____________________________ Address_____________________________

___________________________________ ___________________________________

E-Mail______________________________ E-Mail______________________________

SCCA Member ? _____________________ SCCA Member ? _____________________

Region____________ Number___________ Region____________ Number___________

Minor ? _____________________________ Minor ? _____________________________

Vehicle:

Make_____________________Model______________________ Yr_______ Color_______

License Number____________________ State_______________

Does either competitor own this vehicle? ________ Do you need Late Registration? ____

Class of Entry:

Equipped _____ Limited _____ Stock _____ Rookie _____ Course___ Tour ___ Both ___

I hereby warrant that the above entered vehicle is on the road legally, is being used by the entrant

with the owners permission, and is covered by liability insurance of not less than

$20,000/$40,000/$10,000 or the minimum requirements of the state registry, whichever is higher.

_____________________________ _____________________________ ________

Driver Signature Navigator Signature Date

Mail completed entry forms:

CCR Members: Single rally $85 Both Rallies $160

C/o: Jim Hathcock Non-members add $5 per event.

703 Cruse Road Lot 11

Salisbury NC 28146-7894 Make checks payable to Jim Hathcock