1.-amgia.docVIP

16811 Hale Avenue, Suite A, Irvine, CA 92606 855 372-4227 RACECAR Fax: 949 336-4347 SECTION I –GENERAL INFORMATION PLEASE COMPLETE EVERY ITEM OR INDICATE N/A 1. Name of Applicant: Requested Effective Date: DBA: If applicable, include DBA or Trade Name. 2. Mailing Address: Street City State Zip Code 3. Web Site Address: 4. Contact Name: Title: Phone: Fax: E-mail: 5. Business Type: Individual Partnership Corporation LLC Other Describe : SECTION II – DRIVERS PLEASE COMPLETE EVERY ITEM OR INDICATE N/A 1. Please provide the following information for each Driver: Driver Name D/O/B State Drivers License # Competition License # 1 2 Driver Yrs Competition Lic Held Association e.g. NHRA, IHRA Association Membership # Expiration Date 1 2 2. Has any scheduled Driver’s State or Competition License been suspended or revoked within the last 5 years? Yes No SECTION III – RACE VEHICLES PLEASE COMPLETE EVERY ITEM OR INDICATE N/A 1. Please provide the following information for each Race Vehicle: Vehicle Year Make Model Chassis Tag/Vin # 1 2 Vehicle Chassis Mfg Date Built Chassis Material Chassis Certification # Chassis Cert Exp Date 1 2 Vehicle Class Vehicle Runs In Max MPH Engine Mfg CID HP 1 2 Vehicle Transmission Mfg Transmission Type Converter Type Wheelbase Length 1 Automatic Manual 2 Automatic Manual Vehicle Blower? Supercharger? Nitro Methane Injected? Rear-end Center Mfg 1 Yes No Yes No Yes No 2 Yes No Yes No Yes No Vehicle Used on Public Roads? Value of Complete Vehicle 1 Yes No $ 2 Yes No $ SECTION IV – EQUIPMENT SCHEDULE PLEASE COMPLETE EVERY ITEM OR INDICATE N/A 1. Please describe all Equipment and provide the corresponding Serial Number, Value and desired Deductible: Item Description Serial Number Value 1 $ 2 $ 3 $ 4 $ 5 $ 6 $ 7 $ 8 $ 9 $ 10 $ SECTION V– STORAGE PLEASE COMPLETE EVERY ITEM OR INDICATE N/A 1. Storage Address: Street City State Zip Code 2. Building Constru