The Chattanooga Region, SCCA
Border Line RoadRally
September 18, 2004

DRIVER INFORMATION:

Driver's Name:
 SCCA Membership #:
Street Address:
 Region:
City:
 State:
 Zip:
 You do not have to be an 
SCCA member to participate 
in this event.
Telephone:
 Email:

NAVIGATOR INFORMATION:

Navigator's Name:
 SCCA Membership #:
Street Address:
 Region:
City:
 State:
 Zip:
 You do not have to be an 
SCCA member to participate 
in this event.
Telephone:
 Email:

VEHICLE INFORMATION: 

Make:
 		 Model:
 Color:
 		 Year:
Class: (only one class)
Tag #:
 State:

By entering this event I hereby warrant that the above vehicle is on the road legally, is being 
used by the entrant with the owner's permission and is covered by liability insurance of 
not less than $20,000/$40/000/$10,000

ADDITIONAL INFORMATION:

Entry Fee   Entry Fee will be
collected at registration.
$ 15 Show SCCA Card
$ 20 Non-Member
 
Select "Submit" to send
 this form to Registrar.		 Select "Reset" to clear
 all fields in form.

Contact Mike Strawbridge at mlstrawscca@yahoo.com or 423-559-9633
for more information or to withdraw for this event.

 
Chattanooga Region SCCA      RoadRally

www.rivergate5speed.com
August 14, 2004