$30.00 Membership (to include FREE choice of T-shirt or hat)

Fan Club Member Packet includes:
Newsletters
Invitation to special Fan Club events
Select Lance Dewease Fan Club merchandise
Discount on other Lance Dewease merchandise
Membership for 1 Full Year from sign-up date

PLEASE PRINT

Name: _______________________________________

Address: _____________________________________ Telephone: (_____)_______________

____________________________________________ E-mail address __________________

____________________________________________

____________________________________________ T-shirt size ___________

What kind of things would you like the fan club to offer? ___________________________________

__________________________________________________________________________________

What would you like to know about Lance? _____________________________________________

__________________________________________________________________________________

If available, would you like to receive your newsletter via E-mail? ___________________________

Please send Certified Check, Money Order, VISA, Mastercard or Personal Check (cleared) to:
Tina Chamberlain
c/o Infinity Designs
1500 East Main St.
Waynesboro, PA 17268

Charge card info: Name on card: _____________________________________________________

Account#: __________________________________ Exp. Date: ____________

Type of card: VISA MASTERCARD DISCOVER

Signature: _________________________________________________________

OR bring this form, along with payment, to the races to the Lance Dewease T-shirt sales area.

THANKS FOR BEING A PART OF THE DEWEASE RACING FAMILY!