SIGN UP FOR THE POWERGLIDE PROMODS

Registration Form

Fee: $300    

Make Checks Payable to Heads-Up Door Slammers

Mail to:      Rory Kennedy
                        504 White Oak Dr.
                                   Virginia Beach, VA 23462

Driver’s Name: _______________________________________________

Address: ____________________________________________________

Phone: _____________________   E-mail: _________________________

Car Make: __________________   Model: _________________________

Engine Make: _______________   Cubic Inch: ________  Car #_______

Car Owner: __________________________________________________

Car Sponsor (s): _______________________________________________

Driver’s Profile: ______________________________________________

                          ______________________________________________

If possible please include photo of the car.