Please fill out this form and click the "submit" button below:

Registration Form: Please fill in completely

Driver's name:

Navigator's Name:

Address:

City, State, Zip:

Telephone:

  E-Mail:

IMPORTANT: Please list your full E-Mail Address ie: JohnPublic@AOL.com  

Room choice:

 King, non-smoking King, smoking Double, non-smoking Double, smoking

Staying over Sunday night?

 Yes No     (This will be only an additional $68).

There will be a limited number of cars!

Amount you are sending:

$100 deposit only $235 full fee $303 full fee (incl. Sunday stay-over)

Feel free to type any comments:

Disclaimer:

This is strictly a pleasure event and the registrant will not hold any of the organizers responsible for anything!
After you click the "SUBMIT" button below to submit this form, please send a check made out to Buzz Nielsen for either $100, $235 (or $303 if you plan to stay over Sunday) to:

                  Buzz & Jackie Nielsen
                  PO Box 656
                  Lithia, FL 33547

If you have any problems submitting your Order Form, click HERE to email us about your problem.

Note: If, after you press the "SUBMIT" button, you don't get a screen letting you know that your form has been successfuly sent, use your browser's "BACK" button to return to this form; you've left out one or more required fields. Fix 'em and try again.