MEMBERSHIP APPLICATION

DUES: Husband&Wife $23_______Single Sr. Citizen $10_______Husband &Wife Sr. $13_______Children 6-17 w/adult $5_______Children 6-17 no adult $8_______

           Single Adult 18-over $18_______Lifetime Member existing member 75 or over FREE_______Families having 2 or more kids 6-17,pay only for first two!

NAME_____________________________________________________________________________________PHONE___________________________________________

ADDRESS____________________________________________________________CITY__________________________________STATE__________ZIP______________

CHILDREN:

NAME_________________________________________________DOB________________NAME_____________________________________________DOB_____________

NAME_________________________________________________DOB________________NAME_____________________________________________DOB_____________

EMAIL ADDRESS______________________________________________________IF YOU WOULD LIKE NEWSLETTER EMAILED TO YOU, CHECK HERE_______

CHECK HERE IF DRIVER______CAR#_____________TRACK____________________________________________DIVISION____________________________________

*Make checks payable to Twin State Auto Racing Club, PO BOX 2351, Youngstown, OH 44509.