Nor-Cal Dwarf Car Association

3165 N. Holly drive

Tracy, Cal. 95376 209)832-8508

2016 Membership Application

CAR OWNER:_______________________________________________________


CITY___________________ STATE:____________________ ZIP:___________

PHONE #:_______________________WK. #________________________________

EMAIL ADDRESS:____________________________________________

SOC. SEC#: _______________________

DRIVER'S NAME (if different from owner)_______________________________

DRIVER'S SPOUSE NAME:_________________________________________

DRIVER BIRTHDATE:_______________SPOUSE BIRTHDATE:_________________

CAR OWNERS BIRTHDATE (if different from driver)_____________________

CAR YEAR/BODY STYLE:________________________________________________

CAR # 1ST CHOICE: ________ 2NDCHOICE________ 3RD CHOICE_________




PREVIOUS EXPERIENCE:________________________________________________


ANNUAL DUES: $100.00 (Includes owner's card and driver's card)

each. Membership expires 11/31.

I hereby apply for membership in the N.C.D.C.A.

Liability release: In consideration of the acceptance of the right to participate, entrants, participants, and spectator's, by the execution of this form, release, and discharge the NCDCA and their officer's director's, employees, agents, representatives, members, and servants and anyone else connected with the management for this event of and from any and all injuries and damages, whether the same is known or unknown, inquires, losses, judgements, and or claims from any causes or damages whatsoever that may be suffered by an entrant to his person or property. Further, each entrant, participant, or spectator expressly agrees to indemnify and hold harmless all of the foregoing entities, firms, persons, and bodies of and from any and all liability occasioned or resulting from the conduct of entrants or any and all liability occasioned or resulting from the conduct of entrants or any participants assisting or cooperating with entrant or any participants assisiting or cooperating with entrant and under the direction and control of entrant.

SIGNATURE OF APPLICANT:________________________DATE:_______________