PLEASE PRINT AND MAIL THE REGISTRATION FORM TO: Stephen Buckley 16402 SW Estuary Dr. #108 Beaverton, OR 97006 USA Name: ____________________________________________ Male/Female: ______ Age: ________ Occupation: _______________________________________ Telephone (h): ________________ Telephone (w): ________________ E-Mail: ___________________________________________ Address:___________________________________________ City: _________________ State: _______________________ Country: ______________ Postal Code: __________________ 3 day Elite session - October 2007 3 Day Elite Session - January 2008 3 Day Elite Session - March 2008 Payment Enclosed: $_________ ~MAKE CHECKS PAYABLE TO STEPHEN BUCKLEY~ ~ A $500.00 deposit is required to hold your slot - THE BALANCE IS DUE ON THE FIRST DAY OF INSTRUCTION ~ ~ VISA, Master Card, Cashiers Checks, Money Orders and Personal Checks accepted~ ***Deposits are refundable upon written request 30 days prior to the first day of training. There will be a non-refundable $100.00 application and administrative fee charged if cancelled after 21 day grace period*** ***The Motorsports Driving Academy reserves the right to cancel any driving session that does not meet the minimum attendance required*** ________________________________________ Student Signature & Date ________________________________________ Parent or Guardian signature if student is under 18 years of age Please notify us by E-mail if you have sent an application...Thank You! email: Stuntdriver911@hotmail.com