CIRCUIT GRAND BAYOU 

GULF COAST RACE SERIES

PLEASE PRINT                           DATE:  __________    

Driver’s Name_________________________________

Driver License State ____   #________________

Email address: ____________________________________________

Address: _____________________________________

City: __________________State: _____ Zip: ________

Telephone #: (Home) _______________________________ (Cell): _________________________________

In Case of Emergency: 

Contact Name_______________________________

Phone Number____________________________

Car Info:  Year & Model____________________________ Color: ________________________

Indicate Car Number: 1st Choice_______ 2nd Choice______ 3rd Choice________

Racing Class (Circle One):          

 Red Bracket              Yellow Bracket             Spec Miata             Formula              Production GT1         Production GT2                Production GT3

TRANSPONDER #:  ____________________

I hereby certify that I have no known physical or mental problems which might jeopardize others or me if I participate in this event.

Driver’s Signature _______________________________________________ Date _________________

THE CIRCUIT AT GRAND BAYOU RESERVES THE RIGHT TO REFUSE ANY APPLICATION.

REGISTRATION FEE

______Test & Tune day plus Race day - $310         

______Race day only - $165

Cash is accepted or make check payable to:   

Circuit Grand Bayou, LLC

CASH __________                CHECK # _________                            AMOUNT _________