Pre-Registration for 2011 Show

Name ___________________________ Address ________________________ City ____________________________ State ___________________________ Zip Code ________________________ Phone #:________________________

E-Mail Address:___________________________

Year & Make of Car_____________________ Club Affiliation:_______________________ Comments:___________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Shirt Size: S M L XL 2X 3X (circle one)

Please print and mail along with $15 check made payable to Igniters Street Rods Mail to: Igniters Street Rods, 81 Lakeview Drive, Chillicothe, OH 45601