2005 Membership Application *One form per applicant - Please make copies of this form if additional copies are necessary. Memberships expire December 31, 2005 Type of Membership (please check one) X USE ONLY Member # ______________________ Date __________________________ Member:($150.00) Mandatory for all drivers who will participate in competition or practice for Legends Cars, Bandolero and/or Thunder Roadster Cars. ($50.00 more if driving in two Series - total of $175.00) Associate Member: ($60.00) For anyone who will not drive a Legends Car, Bandolero Car and/or Thunder Roadster Car in competition or practice during the year, but will go into the pit area during Legends, Bandolero or Thunder Roadster Cars events (i.e. pit crew, car owner, spouse, etc.) Associate members receive the same insurance benefits as member except they may not drive. Associates are also eligible for voting, receiving special INEX awards and possible discounted pit fees at selected INEX sanctioned events and tracks. Please print clearly or type (below): Name of Applicant:_____________________________________________ Address:______________________________________________________ City, _______________State,_________ and ZIP___________________ Phone(home):___________(work):______________(fax):_______________ Email address:_________________________________________________ Social Security #:______________________________________________ Date of birth:___________________________________________________ Emergency Contact (Name and number):__________________________ Beneficiary (Name and number):__________________________________ Division (check one): Legends Cars Bandolero Cars Thunder Roadster Cars Pro - "Experienced" or "Expert" racers Masters - over 40 years of age only Semi-Pro - "Intermediate" or "Beginners" Bandits (ages 8-11) Young Guns (ages 12-16) Outlaws (17 and older) Must be 16 years old Young Lions - (ages 12-16) A special application is necessary If car driver and car owner are two different people, car owner information must be filled out-otherwise, NO Membership Card. Car owner information (place "SAME" in name if identical to above): Name of Applicant:_____________________________________________ Address:_____________________________________________________ City, State, and ZIP:____________________________________________ Phone (home):______________(work):___________(fax):______________ Email address:_________________________________________________ Social Security #:______________________________________________ Chassis (VIN) Number(s) - all cars if more than one:__________________ VIN NUMBER IS MANDATORY-NO VIN NUMBER, NO MEMBERSHIP CARD. AGREEMENT / RELEASE I hereby certify that I am an independent contractor, assuming all responsibility for moneys received as a result of my participation in INEX sanctioned events, including without eliminating income taxes, FICA, workmen's compensation and withholding taxes. I am not an employee, servant or agent of INEX Corp. In consideration of acceptance by INEX of this application and payment of membership fees, the undersigned agrees to abide by all rules and regulations of INEX as to conduct and mechanical specifications, as now published in the 2005 Official INEX Rulebook or hereafter modified. The undersigned understands and agrees that s/he and their beneficiaries, executors and assigns will be entitled to the benefits of the Member Insurance Policy by INEX for accidental injuries or death which occur as the result of external, violent and visible means, sustained in INEX sanctioned events. The coverage of the said policy shall constitute the limit of liability of INEX and 600 Racing, Inc. for such injuries occurring to the undersigned in any INEX sanctioned event, provided proper notification of such occurrence is filed with INEX. The undersigned fully understands that operation of a Legends, Bandolero or Thunder Roadster Car exposes him or her to risks of serious bodily injury or death. The undersigned voluntarily assumes these risks. The undersigned consents to the use of his/her name and/or pictures of himself/herself and his/her car, for publicity, advertising, endorsements, both before and after the INEX sanctioned events, and relinquishes any rights to photos taken in connection with INEX sanctioned events, and consents to the publication of sale of such photos by INEX. Any dispute, controversy or claim involving the undersigned member, whether or not relating to this agreement or alleged breach of the same, shall be settled in accordance with the existing and/or amended rules and regulations of INEX, 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 INEX. Signature____________________________________________ Date___________________________ If the applicant is under 18 years of age, a minor/parent release must be executed and filed with this application and a birth certificate, or the applicant will not be permitted to compete. (Contact INEX for appropriate releases). Please return this form, signed and dated, and check/money order payable to: INEX Corp., 5245 NC Hwy. 49 South, Harrisburg, NC 28075. Phone (704) 455-3906 Fax (704) 455-3820