HMSAOnline Priority Registration Form
Champion's Grand Prix
Thunderhill, Willows CA
April 21-22, 2012

Entry Fee $525
To reserve your space today, please complete the form below.
All fields with an asterisk (*) are required.

Driver Name*


Address*


City*

State*

Zip*

Home Phone*

Work Phone

Fax

E-mail adresss*

Car*

Car Number* (list first, second and third choices)

HMSA Class*


Entry Fees

HMSA Member Number

$525 Race

Payment Information
(Online processing requires credit card. For payment by cash or check, please download race form and mail to the HMSA Office)
(check one)*:

MasterCard Visa Discover

Credit Card Number*:

Credit Card Expiration*:

Security Number*(on back of card):


Name on Credit Card*:


Billing Address (if different than above) :
Address

City

State

Zip