PIT PAD ORDER FORM

Driver’s Name:___________________________________________________

Car Number:_____________________________________________________

Division:________________________________________________________

Pit Pad Number in 2011:___________________________________________

Pit Pad Number requested for 2012:__________________________________

Pit Pad Fee for 2012 - $113 taxes included

Payment Options:

1.  Cheque made payable to Barrie Speedway Inc.

2.  Cash

3.  Credit Card:  (Circle One)                   Mastercard                                    Visa                            

Card Number:______________________________________________________

Name as it appears on card:___________________________________________

Expiration Date:_________________  Security Code:______________________

Signature:_________________________________________________________

Amount charged on card:_____________________________________________

HST Reg No. 820472603RT0001