First Name Last Name Address City State Select Not in USA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone E-mail EMERGENCY CONTACT Name Phone Have you ever held a roadracing license? Yes No Organization Requested number Option #1 Option #2 Option #3 Date of Birth mm January February March April May June July August September October November December dd 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 "Riders under 18 legally can't agree so a parent or guardian must sign the printable version and mail it in or pass by our office to sign it." I have read this application in it's entirety and stipulate, under the penalty of perjury, that all statistical information set forth herein by me is true and accurate and complete. In consideration for granting me a competition license by the Florida Mini Roadracing Association, LLC (hereafter referred to as FLAMRA), and in consideration of the promotion and operation of roadrace events by FLAMRA, and in consideration of granting of permission to enter, use and remain on the track facilities and/or premises at which these events take place by the owners and representatives thereof, I hereby, for myself, my heirs, personal representatives and assigns, release, discharge, and agree to hold blameless and indemnify FLAMRA, it's representatives, the owners and representatives of the aforementioned track facilities and/or premises, as well as directors, officers, agents, employees and/or members of all of them and from any liability, loss, claims, demands and possible causes of action that may otherwise accrue from any loss, damage, injury (including death) to my person and property, in any way a result from, or arising in connection with, or related to any event, and whether arising, while engaged in competition or in practice or preparation thereof, while upon entering or departing from said track facilities and or premises, from any cause whatsoever including without limitation, the failure of anyone to enforce rules or regulations, failure to make inspections, of the negligence of other persons. I understand that motorcycle racing competition can constitute a hazardous activity and that by reason of my application for a FLAMRA roadrace license and /or participation in or presence at any competition event, I am assuming all risks and hazards related thereto. I agree that FLAMRA may use my name and likeness, including pictures of my racing equipment and pictures taken at any event, for the purpose of media and promotion. I agree to abide by FLAMRA rules and respect the authority of the race officials and personnel at all events. I hereby confirm, consent and agree to the foregoing.

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