May - California Central Coast - Porsche Club of America

Purveyors of new Volvo, Lotus and Mitsubishi Cars Sales, Parts and Service for Porsche
www.smithvolvo.com sgsmotorsports.com
Buttonwillow 2011 Drivers Education Registration Form
Driver 1 Driver 2
Street
City State
D1 email D2 email
Porsche/Other Model Car Color
Car Year
D1 Preferred Car Number
D1 PCA Membership Number
D1 PCA Region
Street
ZIP ZIP
D2 PCA Region
California Central Coast Porsche Club Of America May 2011
City State
D1 Tee Shirt Size& type(M/F) D2 Tee Shirt Size & type (M/F)
D2 Preferred Car Number
D2 PCA Membership Number
D1 Drivers License # State D2 Drivers License #
State
D1 License Expiration Date D2 License Expiration Date
Driver 1 - Number of TT, AX, DE
in last 2 years?
Driver 1 - How would you rate yourself(Novice,
Inter., Adv., PCA Cert. Instructor)?
Driver 2 - Number of TT, AX, DE
inlast 2 years
Driver 2 - How would you rate yourself(Novice,
Inter., Adv., PCA Cert. Instructor)?
Driver 1 - Do you want a FREE Instructor? : Driver 2 - Do you want a FREE Instructor? :
Instructor - Instructor -
D1 Run Group = D2 Run Group =
Send with check(s) to : Jon Milledge; 2116 Del Norte St.; Los Osos, CA 93402
PCA 1st Driver $170, 2nd Driver $120; NonPCA 1st Driver $190, 2nd Driver $140
ALL EARLY (before May 1) ENTRANTS RECEIVE EVENT LONGSLEEVE T-SHIRT
Late Entrants add $10 to each drivers fee.
INSTRUCTOR Entry $75 to drive your car- Free otherwise. Make check payable to PCA-CCCR.
Upon receipt, an entry packet will be mailed or emailed to Driver 1 containing Tech Form,
Schedule, Rules, etc.
Amount Paid
11