Mid South Racing, LLC

Contact:  Henry Coghlan 662- 571-5176

2008 - Dirt Drag Membership Form

Name __________________________________________________

Address ________________________________________________

City _________________________ State ________ Zip _________

Day Phone____ - ___ - _____ Night Phone ____ - ____ - ________

E-Mail ________________________

Truck Name & Number___________________________________

Class__________________________

Individual membership $25.00 [ ]

Truck Membership $40.00 [ ]

(Truck and Driver must be a member)

If paying by check make payable to Mid South Racing, LLC

Amount Paid _______ [ ] Cash [ ] Check

Mail your membership form & check to:

Mid South Racing, LLC

P.O. Box 15

Holly Bluff , Ms. 39088