The undersigned hereby applies for membership as: *

Select one

DRIVER $150

OWNER $150

OWNER/DRIVER $200

TEMP DRIVER $75

TEMP OWNER $75

TEMP OWNER/DRIVER $100

ASSOCIATE $35

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Date of Birth *

MM

DD

YYYY

Name 1 *

First Name

Last Name

Address 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone 1 *

(###)

###

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Category: Check One Driver STIDA Insurance (Coverage 1/1/2024 – 1/1/2025)

Green Membership

White Membership

Checkered Membership

Waiving personal 3rd layer insurance option

WAIVER *

In consideration of the acceptance by ATQMRA Inc. of my membership application and issuance of same, I do hereby, release, rescind, and discharge ATQMRA Inc., the promoters, presenting races, or other events under ATQMRA sanction, and the owners and lessees of premises in which ATQMRA Inc. sanctioned races or other events are promoted. And the officers, directors, agents, employees, and servants aforementioned, of and from all liability, claims, actions, and possible causes of action, whosoever, may accrue to me or my heirs, next of kin, and personal representative, from any and every loss, damage and injury (including death) that may be sustained by my person ad property, while in, about and enroute into and out of premises where ATQMRA Inc. sanctioned races or other events are presented. I have read and fully understand the foregoing and certify and represent that the above answers are true. I agree to abide by the rules and regulations of ATQMRA Inc. and to accept in final, all decisions of properly authorized ATQMRA Inc. officials.

I have read, understand and accept the waiver.