REGISTRATION FORM

2006 14^th NCRS Heart of America Regional    June 8-10, 2006

St. Louis, MO

Name:  Spouse / Companion:

Address:  City: State:    Zip:

Phone: (Home)  Work: Fax:

Current NCRS Membership #: E-mail:

CORVETTE REGISTRATION: (One Registration form per car)

Flight Judging Entry:

@ $45

@ $45

@ $20

FREE

Founders Operations Check: 

@ $20

  Make Checks Payable to 'NCRS Heart of America Regional'      Total: 

Car Information:  Year  Coupe Convertible

Engine CI/HP:  Complete VIN:  

JUDGING PARTICIPATION

I would like to Judge in class: 

1^st Choice:

2^nd Choice:

Judging Level:

I would like to Judge : 

Int:     Ext:    Mech:

    Class:

I would like to be an observer judge:   I would like to tabulate:   Tabulation level:

Hold Harmless Agreement:

I agree to insure my vehicle and property against loss, damage & liability and to provide proof of such insurance to NCRS. I agree to assume the risk of any and all damage or injury and to indemnify and hold harmless NCRS, its officers, directors, agents, employees, and chapters for any such acts of omissions which may result in the theft, damage or destruction of my property or injury to me or others occurring during or as a consequence of this meet, wherever located.

Signature _______________________Date: Insured with:   

Policy Number:  Expires