5th Annual PT CRUISER Midwest Regional Registration Form.

Registration Fee as of 08/28/04 $45 (Free Event T-Shirt ONLY if Pre-Registered by August 14th 2003.) Fee is per Car. This years event is being held in Winfield, KS ONLY!

Print and Fill out form completely. Please, let us know how many BBQ Passes you will be needing. Limited Quantities of T-Shirts for sale available day of the Event.

Send to Richard Zimmerman, 3818 Wesley Drive, Wichita, Kansas 67227

Check are to be made out to: Richard Zimmerman.

5th Annual PT Cruiser
Midwest Regional

Name:____________________________________

Address:_________________________________

City:______________________

State:____________ ZIP:_________

Phone:_______________________________

EMail Address:___________________

Year:__________ Make:________________

Model:_________________________

Color:___________________ BBQ

Passes:_____________

ONE FREE EVENT SHIRT -

SIZE_____________________
EVENT SHIRTS ( S-XL $15.00 - XXL - XXXL $17.00)____________________________

Registration Fee as of 08/28/04 $45

___________________
Post marked after 08/28/04

$50_______________________

Total____________________

*Event management, Sponsors, City of Winfeild, PTCC and the Winfeild Motor Company (by
execution of this form) are released and discharged of liabilities known and unknown, injuries, losses, judgements and/or claims resulting from the conduct of participants and spectators.

*SIGN________________________

Hotel Information:
Super 8 (Host Hotel)
(620) 229-8888
3803 Pike Road, Winfield, KS 67156

Comfort Inn at Quail Ridge
(620) 221-7529
HWY 77 at Quail Ridge Drive, Winfield, KS
67156

Best Value Camelot Inn
(620) 221-9050
1710 Main Winfield, KS 67156

Sonner Motor Inn
1 (620) 221-4400
1812 Main St.
Winfield KS 67156