Contact Information:

Name:
Address:
City:    State:       Zip:
Phone:
Email:

Vehicle Information:

Vehicle:
Type: Stock Modified

T-Shirt Information:

T-Shirt Size: X-Large 2X-Large 3X-Large
Additional T-shirts: Quantity:      Size: X 2X 3X

Sponsor Information:

Send Sponsor Information: Yes No

 

Send $20.00 pre-registration fee to:
Shawn B. Linehan
11225 Davenport St Suite 104
Omaha NE 68154
Attn: Autoshow
Make checks payable to: Millard Days