ECMSA FALL SHOOTOUT RACE ENTRY FORM

ECMSA 13th Annual 750cc Fall Shootout

Saturday September 25, 2010

Held at Whipcity Speedway

Westfield, MA

PRE-ENTRY FORM

Must be postmarked by September 10th 2010

Pre-entry price

ECMSA member: $20.00

Non-Members: $50.00

Non-pre entry price

ECMSA members $30.00

Non- members $60.00

** must be a member paid in full as of Aug 31, 2010 to recieve discounted entrry fee**

Entry does not include pit pass

Driver Name:_______________________________________________________________

Address: ( for purse payout) :_________________________________________________

_________________________________________________

_________________________________________________

Phone: _____________________________________________

Car #:____________________________-

CAr Owner:_______________________________________________

ECMSA member:( circle one)   Yes     /    No

Sponsor Info: ____________________________________________________________

_________________________________________________________________________

Please mail this form with payment to

Larry King

126 Tavistock St

Springfield , Mass 01119

413-782-7408