INSTRUCTOR INFORMATION
Greetings Instructors!
Welcome to the AlfaMiglia Nordest Time Trial Event.
This is a formal application form for selection if instructors willing to participate in this event with the choice
of instructing only (with track time) or instructing and competing at the time trials (for a small nominal fee
of $50).
We kindly request you complete the application from so I can confirm your participation.
Notes:
 This application form is for instructors only wishing to participate at the June 25, 2015 Alfa
Convention Time Trial event at Thompson Motor Speedway.
 Completing this application form does not imply acceptance or confirmation as an instructor.
 A separate e-mail with confirmation as instructors as well as “registration information” along with
payment information (if competing in TT)
Upon completing this form, please submit to the attention of Stephan de Penasse – Time Trial Chair – at:
Stephan.depenasse@gmail.com
Grazie mille!
Stephan
INSTRUCTOR INFORMATION
Name:
Date of birth:(DD/MM/YY):
Shirt size?
Participating at Time Trial (Y/N)?
City:
State:
ZIP Code:
E-mail:
Phone:
Cell:
Current address:
INSTRUCTOR EXPERIENCE
Current Car Club(s):
How long
actively instructing?
Club License No(s):
Experience at Thompson (Y/N)?
How many events at TMS?
Last event as instructor?
Track location?
References
(ex: Club’s Chief Instructor):
E-mail:
Contact Phone:
Club website(s):
CAR INFORMATION
Car year/make/model:
AROC Class (refer to AROC Nat’l Competition Code – page 13):
Engine Size (cc):
HP:
No. Cylinders:
Modifications:
EMERGENCY & MEDICAL CONTACT INFORMATION
Contact Name:
Relation:
Cell:
Phone:
Medical Insurance Provider:
Insurance Policy Number:
Doctor contact name:
Phone:
City:
State:
Medical information (list any conditions we should know in case of emergency):
ZIP Code: