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2004 LONGISLANDJAM.COM/1-877-CAN RACE FEEL THE THRILL DAY


Personal Information:
Full Name:
Date of Birth (MM/DD/YYYY):
Have Valid Driver License? Yes
No
Address:
City:
State:
ZIP Code:
Phone Number (include area code):
Preferences:
Type of Car: Modified
Late Model Pro Stock
NASCAR Cup
## of Laps:
Note:  Must be 18 and possess a valid Driver's License to race 24 or 50 lap programs).
24 laps - $199.99 (reg. $399.99)
50 laps - $399.99 (reg. $799.99)
Ride With a Pro - $49.99 (reg. $59.99)
Want In Car Video?
$49.99 for 24, 50 lap programs. $19.99 for Ride with a Pro.
Yes
No
Interested in Bus travel?
Price to be determined.
Yes
No
Any other questions or comments?
Name of Person Filling
out this Form (REQUIRED):
E-mail address (REQUIRED):

... or ...
 





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