2008 LICENSE
								APPLICATION
ENTRANT MEMBERSHIP AND INSURANCE BENEFIT PLAN CONTRACT
In order to participate in 2008 racing events at Marshfield Super Speedway, all entrants must complete and
have on file with the Speedway this membership and insurance benefit plan registration.
DIVISION		TYPE MEMBERSHIP		FEE	CAR REGISTRATION		DO NOT WRITE IN THIS SPACE
(    )  Super Late Model		(    ) Driver		$10.00
(    )  Super Stock		(    ) Pit Crew		$10.00	Car #:		Date Filed:
(    )  4-Cylinder					Yr./Make
(    )  Motorcycle
(    )  Pure Stock							License #:
(    )  Junkyard W.
NAME, Last				First				Initial
HOME ADDRESS:					City:			Zip:
TELEPHONES:  Home				Business			Emergency, other
Age			Date of Birth			Place of Birth
Social Security #						Driver License#
FAMILY:  Spouse's Name					Children's Names, Ages
Family's Address/Phone (If other than above)
If Unmarried, Name/Address of Parent or Nearest Relative
EMPLOYMENT Employer					Your      Occupation
Employer Address
Date of Last Physical Exam				Physical Condition		Any Handicaps or Disabilities?  (    ) No  (    ) Yes*
*If Handicaps or Disabilities exist, describe:
HEALTH INSURANCE:  Name of Company						Type:  (    ) Group  or  (    ) Individual
BENEFICIARY STATEMENT :  I hereby designate and name as Beneficiary  (    ) Spouse   (    ) Parent   (    ) Other (give name/address)
AGREEMENT
CONTRACT:  I hereby certify that I am an independent contractor, assuming all responsibility for monies received as a result of my
activities at Marshfield Super Speedway, including without eliminating, income taxes, FICA, workmen's compensation, and withholding
taxes.  I am not an employee, servant or agent of the Speedway.
CONSIDERATION AND COMPLIANCE:  In consideration of acceptance by the Speedway of this application and payment of
membership fees, the undersigned agrees to abide by all rules and regulations of the Speedway as to conduct and mechanical
specifications, as now published or hereafter modified.  Undersigned further recognizes his obligation to the public and
the Speedway, which posts the prize monies and conducts the events, and agrees to compete in all events for which he may
be qualified, if humanly possible.  I also have received a copy of the 2008 Rule Book and understand and will abide by all rules and
regulations.
BREACH AND DAMAGE:  In the event the undersigned breaches this agreement, he shall be liable for actual and liquated damages
sustained by the Speedway as a direct or indirect result of such breach.
BENEFITS:  I understand and agree that myself and my executors and assigns will be entitled to the benefits of the Competitor Accident
Insurance Policy procured by the Speedway for accidental injuries or death which occur as the result of external, violent and visible
means, sustained in Speedway events.  The coverage of said policy shall constitute the limit of liability of the Speedway for such injuries
occurring to me in any Speedway event, provided proper notification of such occurrence is filed with the Speedway.
OWNERSHIP:  If owner of a registered racing car, I hereby certify that I have good and marketable title to said vehicle or any part thereof,
in the event same is claimed or sold pursuant to the rules of the Speedway.
ADVERTISING RELEASE:   The undersigned consents to the use of his/her name and/or pictures of himself/herself and his/her car,
for publicity, advertising and endorsements both before and after events and relinquishes any rights to photos taken in connection with
events and consents to the publication or sale of such photos by the Speedway.
ARBITRATION:  Any dispute, controversy or claim involving the undersigned member, whether or not relating to this agreement or alleged
breach of same, shall be settled in accordance with the existing and/or amended rules and regulations of the Speedway, and the undersigned
agrees to accept the decisions rendered by such process.
BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.  I AGREE TO ABIDE
BY ALL TERMS OF THIS AGREEMENT AND THE REQUIREMENTS OF THE RULES OF THE SPEEDWAY.
DATE:                                                 , 2008				Legal Signature
IF APPLICANT IS UNDER 18 YEARS OF AGE, A MINOR/PARENT RELEASE MUST BE EXECUTED AND FILED WITH THIS APPLICATION				Notary