Preregistration Form

Schedule of Events

Saturday, July 17, 2004 7:30-9:00 Autocross Registration 9:00-9:30 Course Orientation 9:30-3:00 Autocross Heats 3:00-4:00 Autocross Awards 6:00-???? Picnic

Sunday, July 18, 2004 8:00-12:00 Show Car Registration 12:30 - 2:00 Voting 12:30 - 4:00 *Door Prizes 4:00 - Trophies Awarded

* Door prize winners will be announced and posted throughout the afternoon.

Please print this form and mail with check or money order by July 3rd to:
"Fords at the Mall"
c/o Rod Dieffenbacher
315 Klump Road
Cogan Station, PA 17728

Autocross (Saturday) - $15/car Picnic (Saturday) - $5/person Car Show (Sunday) - $8/car (Day of show registration will be $10.00) T-shirts: $10/each ($12/each day of show) Med. - Lrg. - X-Lrg. - XX-Lrg.

x ____ = _______ x ____ = _______ x _____ = ______ x _____ = ______ Total Enclosed: ________________

Name:____________________________________ Address:__________________________________ City:_____________________________________ State:_______________ Zip:__________________ Phone:____________________________________ Car Model:___________________ Year:_________