MID-WESTERN AMATEUR DRIVING ASSOCIATION

NOMINATION FORM

2008

Driver’s Name:

Address:

City/State/Zip Code:

Telephone: Home: Work:

Occupation:

Type of Driver’s License: Number:

I need an application form for a Driver’s License: Yes No

U.S.T.A. Membership Number:

I plan to race a:

Trotter Pacer Both in the Amateur Driving Series.

(Please circle one)

I, the undersigned, qualify as an “Amateur Driver” as one who has never accepted any valuable consideration by way of or in lieu of compensation for services as a driver. In addition, I had less than 100 drives in 2007.

Signed: Date:

Nomination Fee: $20 (If paid by June 15, 2008)

Late Nomination Fee: $50 (If paid after June 15, 2008)

Please make checks payable to Mid-Western Amateur Drivers Association

Return to: Illinois Department of Agriculture

Fairs and Promotions

John Cisna

P.O. Box 576

Springfield, IL 62794-9281

Phone: 217/522-8781 (office)

217/546-5258 (home)