DIRTcar UMP MODIFIEDS ENTRY CHECKLIST SAVE $90 BY SEPT 29

Transcription

1 DIRTcar UMP MODIFIEDS ENTRY CHECKLIST SAVE $90 BY SEPT 29 T assist us in making yur 2017 Allstar Perfrmance Fall Natinals Weekend as seamless as pssible, we have put tgether this checklist f the necessary paperwrk required prir t Technical Inspectin. Filing a pre-entry (via mail/express/fax/nline) saves yu bth mney and valued time n race day especially fr thse f yu attending Eldra fr the first-time this seasn. See yu sn! Cmpleted Official Entry Frm fr 2017 Allstar Perfrmance Fall Natinals. Reviewed Eldra Speedway s 2017 Minimum Membership & Safety Standards These are rules, safety requirements and technical specificatins specific t cmpeting at Eldra Speedway see nline at: Submitted 2017 Eldra Driver Membership (if nt already n file yu re reimbursed fr it via yur purse check). Submitted 2017 Eldra Owner Membership (if car wner is different than driver and nt already n file). Submitted W9 (r W8-BEN) t Eldra fr 2017 seasn. Submitted 2017 DIRTcar Membership (must be prcessed by Wrld Racing Grup fr member benefits/insurance cverage). Psted n scial media fr everyne t cme see yu in the 2017 #AllstarFallNattys!

2 OFFICIAL ENTRY FORM ENTER ONLINE, FAX OR MAIL BY FRI, SEPT 29 TO SAVE $90! ***RECORD $153,875 POSTED FOR MODIFIEDS!*** MORE FEATURES! MORE VICTORY LANES! MORE CHANCES TO ADVANCE! MORE $$$ TO START! RANDY LaJOIE SAFETY REVIEW THURSDAY & FRIDAY! INCREASED PAYBACK ALL RACES! FREE CAMPING! POST-RACE PARTY IN THE BARN ON FRIDAY NIGHT! $1 BUSCH LIGHTS ALL WEEKEND! Fur (r mre!) $1,000-t-win Features n Thursday, Oct 5 th! Fur (r mre!) $2,000-t-win Features n Friday, Oct 6 th! Turnament Qualifiers & $5,000-t-win Natinal Champinship n Saturday, Oct 7 th! ***EVERYBODY RACES A FEATURE THURSDAY & FRIDAY*** Ttal number f Heat Races & Features fr Thursday & Friday determined when inspectin clses at 4:30 p.m. Cmpetitrs will scre pints each time they are n the track using Eldra s Every Lap Matters Frmat. DATES: Thursday, Octber 5 th Randm Draw t determine Grups; Multi-Car Time Trials by grup; Eight t 12 Heat Races by Grup (inverted); & FOUR (r mre!) $1,000-t-win 20-lap A-Features. Friday, Octber 6 th Randm Draw t determine Grups; Multi-Car Time Trials by grup; Eight t 12 Heat Races by Grup (inverted); & a minimum f FOUR (r mre!) $2,000-t-win 20-lap A-Features. Saturday, Octber 7 th Fur Turnament Qualifiers seeded with the tp 96 drivers in by ttal pints frm the Every Lap Matters Frmat (lined up in staggered fashin), the $1,000-t-win Crn Maze Dash, the $2,000-t-win Fall Harvest Pursuit, the $3,000-t-win Wabash River Challenge and the $5,000-t-win Allstar Perfrmance Fall Natinals Champinship fr DIRTcar UMP Mdifieds...plus a full DIRTcar UMP Late Mdel prgram and the $5,000-t-win Allstar Perfrmance Fall Natinals Champinship. PROMOTER: Eldra Speedway, Inc. (1/2-mile clay val) State Rute 118, New Westn, OH ELDORA SPEEDWAY, INC. RESERVES THE RIGHT TO REFUSE ANY ENTRY SANCTION: DIRTcar UMP Call fr all mechanical, technical and tire questins: (704) SPECIAL INFORMATION FOR UMP MODIFIEDS READ CAREFULLY DISCLAIMER: The rules and/r regulatins set frth herein are designed t prvide fr the rderly cnduct f racing events and t establish minimum acceptable requirements fr such events. These rules shall gvern the cnditin f all events, and by participating in these events, all participants are deemed t have cmplied with these rules. NO EXPRESSED OR IMPLIED WARRANTY OF SAFETY SHALL RESULT FROM PUBLICATIONS OF OR COMPLIANCE WITH THESE RULES AND/OR REGULATIONS. They are intended as a guide fr the cnduct f the sprt and are in n way a guarantee against injury r death t a participant, spectatr, r fficial. The Race Directr shall be empwered t permit reasnable and apprpriate deviatin frm any f the specificatins herein r impse any further restrictins that in his pinin d nt alter the minimum acceptable requirements. NO EXPRESSED OR IMPLIED WARRANTY OF SAFETY SHALL RESULT FROM SUCH ALTERATION OF SPECIFICATIONS. Any interpretatin r deviatin f these rules is left t the discretin f the fficials. Their decisin is final. This race prgram will be run under Eldra Speedway (Eldra) rules, and in signing an Official Entry Frm (OEF) r taking part in any f the events described in this OEF, all cmpetitrs acknwledge that they have received, read and understand all f the rules and regulatins assciated with the event, and hereby agree t abide by all fficial Eldra decisins and regulatins. Any deviatin f these rules and regulatins may result in fines r penalties including disqualificatin frm the event.

3 EVERY LAP MATTERS FORMAT: when cmpetitrs are n track Thursday and Friday at the 2017 Allstar Perfrmance Fall Natinals Weekend, they will be scring pints via the Every Lap Matters Frmat which seeds the lineups fr Saturday s Turnament Qualifiers. Time Trials: 1) 300; 2) 298; 3) 296; 4) 294; 5) 292; 6) 290; 7) 288; 8) 286; 9) 284; 10) 282; etc. Heat Races: 1) 200; 2) 197; 3) 194; 4) 192; 5) 190; 6) 188; 7) 186; 8) 184; 9) 182; 10) 180; etc. Feature: 1) 500; 2) 496; 3) 492; 4) 488; 5) 484; 6) 480; 7) 476; 8) 472; 9) 468; 10) 464; etc. The riginal green flag must be taken n the track t scre pints in any Time Trial, Heat Race, B-Feature r A-Feature cntest. Drivers nt making a qualificatin attempt, late t qualifying*, and/r nt starting any scheduled race will scre ZERO pints fr that particular prtin f the shw. *A three psitin/ne grup grace MAY be granted during time trials at the discretin f the Officials, hwever, drivers missing their drawn psitin/grup cannt start better than the inverted cars in their next Heat Race regardless f their best-timed lap. Pints fr time trials are awarded t the field in the aggregate. DIRTcar UMP Natinal Pints & Eldra Track Pints: Feature Races cntested during the UMP Fall Natinals Weekend award pints twards the 2017 DIRTcar UMP Natinal Champinships and t drivers participating in the 2017 Eldra Speedway Track Champinship. 1. Minimum age fr cmpetitrs is 16 years f age as f Octber 5, Only persns 14 years f age r lder will be admitted t pit area. Minrs 14, 15, 16 r 17 years f age must submit a Parental Cnsent, Release and Waiver f Liability, Assumptin f Risk, and Indemnity Agreement/Minr's Assumptin f Risk and Release and Waiver f Liability signed by BOTH f their parents (r legal guardians). N exceptins. Dwnlad at: Pit area rules are strictly enfrced. TRIAL REGISTERED PIT VEST PROGRAM FOR CHILDREN OF DRIVERS AGED 13 & YOUNGER Eldra is currently testing a trial Registered Pit Vest prgram fr the children f drivers aged 13 and yunger. A fully cmpleted minr waiver must be executed per the abve instructins, a pit pass purchased and an apprpriately sized and numbered vest is registered and issued t the minr (wh must be accmpanied by a parent when nt in the hauler) and fllw the rules specific t the prgram r they will be remved frm the pit area. 2. All cars will be subject t Eldra/DIRTcar cntrl frm the time they enter the pit area until they are fficially released after the race. 3. Only tw vehicles will be allwed inside pit area. One wrk area vehicle (Arctic Cat/Textrn Off-Rad r similar), per entry, may be presented fr credentialing at Registratin NO RIDERS PERMITTED UNLESS SEAT EXISTS wrk area vehicles must remain in pit area, may be used nly at specified times and may nt be used n unrestricted areas f prperty. Please cperate with these rules s that we may cntinue t ffer this curtesy. 4. It is strngly encuraged that the driver s last name shuld be clearly displayed in BOLD BLOCK LETTERS n bth drs and acrss frnt f rf. 5. DIRTcar-plated tires sized 26.5/8.0/15 r 27.5/8.0/15 nly. Maximum width 9 inches. Hsier M-30S tire is required n the Left Frnt (LF), Right Frnt (RF) and Left Rear (LR) psitins. The M-30S r Hsier M-60 tire permitted n the Right Rear (RR) psitin. N grving permitted. Only the M-60 may be siped when in the RR psitin. Tire rule enfrced accrding t DIRTcar UMP rulebk.

4 6. A Racing Electrnics Sl r RACEceiver ne-way radi and a Westhld scring transpnder is mandatry fr ALL n-track activity. Yu may use yur wn Westhld transpnder r rentals will be available at track. 7. Sunc Race Fuels Start and Restart Zne and prcedures will be detailed at driver meeting. 8. All prize mney will be mailed frm Eldra t designee. Checks will nt be issued withut a verified IRS Frm W-9 (r W-8BEN fr Canadian entrants) n file. All entrants are participating n their wn behalf and are cmpletely independent f the event prmter. As an independent cntractr, entrants are assuming all respnsibilities fr prize mney received including all incme and withhlding taxes that apply t such winnings. 9. Eldra reserves the right t alter shw frmat and revise race prcedures in the event f, but nt limited t, car cunt, inclement weather, challenging track cnditins and/r ther extenuating circumstances. DIRTcar will enfrce and gvern all mechanical, technical and tire regulatins and rules. Mechanical, technical and tire infractins may result in a cmplete lss f all prize mney earned. Eldra reserves right t refuse and/r remve any persn frm Speedway prperty. *ADVANCEMENT, FORMAT & POSTED AWARDS* Subject t Change THURSDAY (minimum $44,500 psted) MULTI-CAR GROUP QUALIFYING Multi-car grup qualifying, using grups determined by randm draw at Inspectin, will be used t determine that grup s Heat Race lineup. The driver s fastest time frm Thursday and Friday will be used as a tiebreaker, if necessary, fr Saturday s lineups. HEAT RACES The preliminary frmat plans fr eight t 12 heat races f 10 laps in distance. The inversin prcedure will be detailed at the Driver Meeting. Heats 1 & 2 will determine the first A-Feature, Heats 3 & 4 will determine the secnd A-Feature, Heats 5 & 6 will determine the third A-Feature, and Heats 7 & 8 will determine the furth A-Feature. If necessary, Heats 9 & 10 will determine the fifth A-Feature and Heats 11 & 12 will determine the sixth A-Feature. A-FEATURES ($11,125 psted per feature race) Thursday night will run fur (r mre) A- Features f 20-laps; starting up t 24 cars. Starting psitins will initially be determined by heat race finish. The redraw prcedure will be detailed at the Driver Meeting. Prize mney will be distributed t finishing psitins as fllws: 1 st ) $1,000; 2 nd ) $750; 3 rd ) $700; 4 th ) $600; 5 th ) $575; 6 th ) $550; 7 th ) $525; 8 th ) $515; 9 th ) $510; 10 th ) $500; 11 th ) $475; 12 th ) $450; 13 th ) $425; 14 th ) $400; 15 th ) $375; 16 th ) $350; 17 th ) $325; 18 th ) $300; 19 th ) $300; 20 th ) $300; 21 st ) $300; 22 nd ) $300; 23 rd ) $300 and 24 th ) $300. Supreme (112 ctane): $8.25/gal & HCR+ (114 ctane): $10.50/gal available until 30 minutes befre Ht Laps frm Sunc Fuel Pumps lcated in Upper Pit Area

5 FRIDAY (minimum $49,600 psted) MULTI-CAR GROUP QUALIFYING Multi-car grup qualifying, using grups determined by randm draw at Inspectin, will be used t determine that grup s Heat Race lineup. The driver s fastest time frm Thursday and Friday will be used as a tiebreaker, if necessary, fr Saturday s lineups. HEAT RACES The preliminary frmat plans fr eight t 12 heat races f 10 laps in distance. The inversin prcedure will be detailed at the Driver Meeting. Heats 1 & 2 will determine the first A-Feature, Heats 3 & 4 will determine the secnd A-Feature, Heats 5 & 6 will determine the third A-Feature, and Heats 7 & 8 will determine the furth A-Feature. If necessary, Heats 9 & 10 will determine the fifth A-Feature and Heats 11 & 12 will determine the sixth A-Feature. A-FEATURES ($12,400 psted per feature race) Friday night will run fur (r mre) A- Features f 20-laps; starting 24 cars. Starting psitins will initially be determined by heat race finish. The redraw prcedure will be detailed at the Driver Meeting. Prize mney will be distributed t finishing psitins as fllws: 1 st ) $2,000; 2 nd ) $1,000; 3 rd ) $750; 4 th ) $700; 5 th ) $600; 6 th ) $575; 7 th ) $550; 8 th ) $525; 9 th ) $500; 10 th ) $475; 11 th ) $450; 12 th ) $425; 13 th ) $400; 14 th ) $375; 15 th ) $350; 16 th ) $325; 17 th ) $300; 18 th ) $300; 19 th ) $300; 20 th ) $300; 21 st ) $300; 22 nd ) $300; 23 rd ) $300; and 24 th ) $300. SATURDAY ($59,775 psted): TOURNAMENT QUALIFIERS (Fur x 15-laps) The tp 96 drivers, seeded by ttal pints frm the Every Lap Matters Frmat, will be staggered int fur Turnament Qualifiers. The high pint driver will start first and the lw pint driver will start last. If mre than 96 drivers are present n the final day f the event, Last Chance Races will be scheduled as necessary and the number f drivers t advance will be annunced. If fewer than 96 drivers are present n the final day f the event, new drivers may register, hwever, new participants may nt start any Feature Race fr which they advance ahead f a driver wh participated in the Thursday and/r Friday prgrams (cars serving penalties excluded). The tp-five finishers frm each Turnament Qualifier will advance t the $5,000-t-win Allstar Perfrmance Fall Natinals Champinship. The drivers with the highest pints ttal, wh d nt finish in the tp-five in their Turnament Qualifier, will be the sixth cars t advance t the Champinship. The next six eligible drivers frm each Turnament Qualifier will advance t the $3,000-twin Wabash River Challenge; the next six eligible drivers frm each Turnament Qualifier will advance t the $2,000-t-win Fall Harvest Pursuit; and the remaining drivers will cmpete in the $1,000-t-win Crn Maze Dash. PROVISIONALS (TWO) The tw drivers highest in the 2017 DIRTcar UMP Natinal Mdified (ne) and Eldra Speedway Champinship standings (ne) wh d nt advance via the Turnament Qualifiers will be granted the final tw starting psitins in the Champinship event.

6 Saturday (cntinued) $1,000-TO-WIN CORN MAZE DASH ($11, laps) The third grup f six drivers wh d nt advance frm the fur Turnament Qualifiers will make up the 24-car starting field. Prize mney will be distributed t finishing psitins as fllws: 1 st ) $1,000; 2 nd ) $750; 3 rd ) $700; 4 th ) $600; 5 th ) $575; 6 th ) $550; 7 th ) $525; 8 th ) $515; 9 th ) $510; 10 th ) $500; 11 th ) $475; 12 th ) $450; 13 th ) $425; 14 th ) $400; 15 th ) $375; 16 th ) $350; 17 th ) $325; 18 th ) $300; 19 th ) $300; 20 th ) $300; 21 st ) $300; 22 nd ) $300; 23 rd ) $300 and 24 th ) $300. $2,000-TO-WIN FALL HARVEST PURSUIT ($12,400 psted 15-laps) The secnd grup f six drivers wh d nt advance frm the fur Turnament Qualifiers will make up the 24-car starting field. Prize mney will be distributed t finishing psitins as fllws: 1 st ) $2,000; 2 nd ) $1,000; 3 rd ) $750; 4 th ) $700; 5 th ) $600; 6 th ) $575; 7 th ) $550; 8 th ) $525; 9 th ) $500; 10 th ) $475; 11 th ) $450; 12 th ) $425; 13 th ) $400; 14 th ) $375; 15 th ) $350; 16 th ) $325; 17 th ) $300; 18 th ) $300; 19 th ) $300; 20 th ) $300; 21 st ) $300; 22 nd ) $300; 23 rd ) $300; and 24 th ) $300. $3,000-TO-WIN WABASH RIVER CHALLENGE ($14,125 psted 20-laps) The first six drivers wh d nt advance frm the fur Turnament Qualifiers will make up the 24-car starting field. Prize mney will be distributed t finishing psitins as fllws: 1 st ) $3,000; 2 nd ) $1,000; 3 rd ) $750; 3 rd ) $700; 4 th ) $600; 5 th ) $575; 6 th ) $550; 7 th ) $525; 8 th ) $515; 9 th ) $510; 10 th ) $500; 11 th ) $475; 12 th ) $450; 13 th ) $425; 14 th ) $400; 15 th ) $375; 16 th ) $350; 17 th ) $325; 18 th ) $300; 19 th ) $300; 20 th ) $300; 21 st ) $300; 22 nd ) $300; 23 rd ) $300 and 24 th ) $300. $5,000-TO-WIN ALLSTAR PERFORMANCE CHAMPIONSHIP ($22,125 psted 30-laps) The tp-five drivers (20) advancing frm the Turnament Qualifiers, plus the high-pint drivers frm each race wh did nt advance (fur), and the DIRTcar and Eldra Champinship prvisinal psitins (tw) will make up the 26-car starting field. Eldra reserves the right t add psitins as Prmter Optins. Prize mney will be distributed t finishing psitins as fllws: 1 st ) $5,000; 2 nd ) $2,000; 3 rd ) $1,750; 4 th ) $1,500; 5 th ) $1,250; 6 th ) $1,000; 7 th ) $750; 8 th ) $700; 9 th ) $650; 10 th ) $600; 11 th ) $550; 12 th ) $500; 13 th ) $450; 14 th ) $445; 15 th ) $440; 16 th ) $435; 17 th ) $430; 18 th ) $425; 19 th ) $420; 20 th ) $415; 21 st ) $410; 22 nd ) $405; 23 rd ) $400; 24 th ) $400; 25 th ) $400; and 26 th ) $400. *** DIRTCAR UMP MINIMUM POST-RACE WEIGHT OF 2,400 POUNDS (CAR WITH DRIVER) IS WEIGHED ON TRACK SCALE*** ELDORA POLICY ONE ROLL OFF & RE-SCALE ATTEMPT ONLY EXCEPT IN RARE INSTANCES (EIRI) ALL PRIZE MONEY PAID BY CHECK ALL RESULTS ARE UNOFFICIAL PENDING POST-RACE INSPECTION AND ANALYSIS Tickets: Thursday-$12; Friday-$12; Saturday-$20 Kids (12 & yunger) FREE in General Admissin nw n sale at r (937) (Add $4 fr Reserved Seat) *** PIT PASSES: Thursday $20 / Friday $20 / Saturday $25 ***

7 *IMPORTANT SCHEDULE NOTES* Hauler staging pens n Wed, Oct 4 at 8 a.m. Please enter grunds via Camping Lt #1 driveway frm Nrth Star-Ft. Lramie Rd t staging area n left. Infield parking will be by hauler size and nt by rder. N spts saved. Click here fr a printable prperty map: Thursday, Octber 5 10:00 a.m. Pit Pass sales begin/credentials pen/pit Gate pens 10:00 a.m. 4:30 p.m. DIRTcar UMP Mdified Registratin/Pill Draw/Tech Inspectin 4:45 p.m. Driver Meeting (mandatry fr driver and ne crew member) 5:30 p.m. Ht Laps/Multi-Car Time Trials 7:00 p.m. Racing Friday, Octber 6 11:00 a.m. Pit Pass sales begin/credentials pen 11:30 a.m. Pit Gate pens 11:30 a.m. 4:30 p.m. DIRTcar UMP Mdified Registratin/Pill Draw/Tech Inspectin 4:45 p.m. Driver Meeting (mandatry fr driver and ne crew member) 5:30 p.m. Multi-Car Time Trials 7:00 p.m. Racing (fllwed by Wrld Famus Eldra Friday Night Party in the Barn) Saturday, Octber 7 11:00 a.m. Pit Pass sales begin/credentials pen 12:00 p.m. Pit Gate pens 12:00 p.m. 4:15 p.m. DIRTcar UMP Late Mdel Registratin/Pill Draw/Tech Inspectin 4:30 p.m. Driver Meeting (mandatry fr driver and ne crew member) 6:00 p.m. Racing *PLEASE POST BY FRI, SEPT 29 NOTE NEW CREDIT CARD, FAX & ONLINE OPTION* EARLY-ENTRY FEE POSTMARK/TIMESTAMP BY SEPT 29: $75 (3-DAY) (INCLUDES 3-DAY DRIVER PIT PASS) LATE-ENTRY POSTMARK/TIMESTAMP AFTER SEPT 29 TRACK: $100 (DOES NOT INCLUDE PIT PASS) PORTION BELOW MUST BE FULLY COMPLETED AND MAILED, WITH ENTRY FEE, TO: ELDORA SPEEDWAY (Attn: UMP FALL NATTYS), State Rute 118, New Westn, OH r FAX t: (937) with (please circle): VISA Mastercard Discver AMEX Expiratin: / Cde: CLIP HERE CLIP HERE CLIP HERE CLIP HERE CLIP HERE 17 UMP FALL NATTYS (MODS) In cnsideratin f Eldra Speedway, Inc. s (Eldra) apprval f this entry applicatin and fr the pprtunity t participate in the event, each f the undersigned agrees as fllws: 1. ACKNOWLEDGEMENT AND AGREEMENT TO ABIDE BY RULES: I acknwledge that I have read and understand all terms and prvisins in the Official Entry Frm and in all Special Rules published by Eldra fr this Event, and that I will abide by all such terms and prvisins, as they may be amended frm time t time, and by all decisins by Eldra r its Officials interpreting and applying them. 2. ADVERTISING AND PROMOTION RELEASE. Eldra, its duly authrized agents and assigns, may use my name, likeness and perfrmance, including phtgraphs, images and sunds f me and/r any vehicle(s) with respect t which I cmpete in Eldra-prmted events, in any way, medium r material (including but nt limited t bradcasts by and thrugh televisin, cable televisin, radi, pay-per-view, clsed circuit televisin, satellite signal, digital signal, film prductins, auditape prductins, transmissins ver the internet, public and private nline services authrized by Eldra, and the like) fr prmting, advertising, r reprting any Eldra-prmted event befre, during and after such event, and I d hereby relinquish t Eldra all rights theret fr such purpses: prvided, hwever, that, I shall retain the exclusive use f my name, picture & likeness in cnnectin with prduct endrsements & the sale f prducts, services, cncessins & merchandise. 3. PERSONAL INJURY AND PROPERTY DAMAGE RELEASE. I hereby release and waive any and all claims pursuant t the RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT as psted and signed at Registratin. 4. ENTRANT S GOOD FAITH TO THE PUBLIC PLEDGE. In recgnitin f the supprt f the racing fans, and the effrt and mnies expended by the spnsrs and Eldra in cnnectin with the Event, I agree t use my best effrts t cmpete in the Event, including related practice and qualifying activity, and I will nt withdraw frm cmpetitin withut the cnsent f Eldra r his designee. If the Driver fr any reasn is unable t cmpete, the Car Owner will use its best effrts t identify and use a substitute driver in rder t cmpete. DRIVER (Print) AGE SSN r Fed. Tax ID # STREET CITY STATE ZIP DRIVER S SIGNATURE/DATE / / PHONE ( ) I acknwledge that I have fully read and understand the rules and regulatins gverning the mechanical and technical requirements fr the event. I assume respnsibility fr the legality and safety f my car and accept all penalties issued by the Race Directr and/r fficials. I acknwledge that I am respnsible fr the actins f my Car Owner, Crew Chief and Pit Crew and that they must abide by all Eldra Speedway rules, regulatins and decisins as well as the stipulatins annunced by the Race Directr and/r fficials. I acknwledge that my event finishing psitin and prize mney may be subject t penalty fr the actins f myself, my Car Owner, Crew Chief and Pit Crew. CAR # 2 nd Chice CHASSIS MAKE COLOR(S) CAR SPONSORS (three) HAULER (H x L) TRANSPONDER # EMERGENCY CONTACT PH ( ) RELATIONSHIP CAR OWNER (Print) SSN r Fed. Tax ID # STREET CITY STATE ZIP OWNER S SIGNATURE/DATE / / PHONE ( ) ALL WINNINGS WILL BE PAID TO THE PERSON/BUSINESS/ENTITY DESIGNATED ON FORM W-9

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