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Please Print the Form and Mail to the PO Box Below

Name: ______________________________________________________________

Address: ____________________________________________________________

City, State, Zip: _______________________________________________________

Phone (home): _________________________

(work): __________________________________

Email: ________________________________

Fax: ____________________________________

Date of Birth: __________________________

Drivers License: __________________________ State: ________

Paid Check #: ___________    Deposit & Prepaid Amount: ____________________

Card #: _____________________________

Mastercard - Visa -  Discover

Expiration Date: ___________  

CSC# = Card Security Code (3 numbers on back of card): _____

Exact Name on Card: ___________________________________

Height: __________   Weight: _______

 

Applicant’s Signature: ______________________________________

Date: ________________

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Please Check the Box of the Course Selected

Ride the Featherlite Modified

Box.gif (2111 bytes) • One Lap Qualifying Run - $ 50.00

    or

Box.gif (2111 bytes) • Two Lap Qualifying Run - $ 90.00

Box.gif (2111 bytes)   Rookie Test Drive
• Drive 15 Laps - $ 375.00

Box.gif (2111 bytes)  Extended Test Drive
• Two 16 Lap Sessions
• Drive 32 Laps - $ 700.00

Box.gif (2111 bytes)   Saturday Night Feature
• Three 15 Lap Sessions
• Drive 45 Laps - $ 1135.00

Box.gif (2111 bytes)  Competition Drive
• Six 15 Lap Sessions
• Drive 90 Laps - $ 2226.00

Box.gif (2111 bytes)  Victory Lane Drive
• One-on-One with Your Instructor
• Drive 50 Laps - $ 2544.00

Date(s) Requested:____________________________________________________


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Drive to Victory Lane

PO Box 60

Thompson, CT 06277

Call: (508) 314-6013

Email:   kbrace4fun@yahoo.com

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