Mail Checks Payable To:
Florida mini Sprint Association or F.M.S.A.
1450 E. Taylor Rd.
Deland, FL 32724
2012 FMSA Membership Application
Driver/Owner: ___________________/______________________ Car #: _______ or ________
Name: __________________________________________________
Address: _______________________________________________
City, State, Zip Code: _______________________________________________
Sponsors: ______________________________________________
Chassis:_______________________________ Engine ____________________ cc
Date of Birth: _______/______/19_______ S.S.N.: _______-_____-_______
PH.#:(_______) _______-_________ EMAIL: ____________________________
Employer: _________________________ Occupation: _____________________
In Case of Emergency
Contact: __________________________________________________
Blood Type: _________________________ Allergies: _____________________
Injury release
I agree that when I participate in any Florida Mini Sprint Association event or function, I do so at my own risk and
that Florida Mini Sprint Association, officers, members, crew, participants or tracks are not responsible for any
bodily injury or any damage to property belonging to myself.
Signed: ___________________________________ Date: _______/______/2012
Membership - $100.00- Includes A&B Transponder Usage During All FMSA Events. Checks Payable to: FMSA
Drivers Must be at least 13 years of Age, except for All FMSA Winternational Events
Florida mini Sprint Association or F.M.S.A.
1450 E. Taylor Rd.
Deland, FL 32724
2012 FMSA Membership Application
Driver/Owner: ___________________/______________________ Car #: _______ or ________
Name: __________________________________________________
Address: _______________________________________________
City, State, Zip Code: _______________________________________________
Sponsors: ______________________________________________
Chassis:_______________________________ Engine ____________________ cc
Date of Birth: _______/______/19_______ S.S.N.: _______-_____-_______
PH.#:(_______) _______-_________ EMAIL: ____________________________
Employer: _________________________ Occupation: _____________________
In Case of Emergency
Contact: __________________________________________________
Blood Type: _________________________ Allergies: _____________________
Injury release
I agree that when I participate in any Florida Mini Sprint Association event or function, I do so at my own risk and
that Florida Mini Sprint Association, officers, members, crew, participants or tracks are not responsible for any
bodily injury or any damage to property belonging to myself.
Signed: ___________________________________ Date: _______/______/2012
Membership - $100.00- Includes A&B Transponder Usage During All FMSA Events. Checks Payable to: FMSA
Drivers Must be at least 13 years of Age, except for All FMSA Winternational Events
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |