Membership Application
Membership dues are $150.00 per year. 10%
off ($135) if paid prior to March 1st.
Please print and fill out all information below. You may pay by cash,
check or credit card.
Mail To:
OSBA Membership
7215-E Telegraph Square Drive
Lorton, VA 22079
OR FAX to: 703.339.3932
Team Name: _______________________________________
Driver Name: _______________________________________
Please circle class you wish to participate in:
C/1
C/2 Unlimited
Drag Radial Index
Sponsors: __________________________________________________________
Phone Number:__________________ E-mail Address:
_________________________________
Address:
Street:
________________________________________________________________
State: ___________________________________
Zip: ________________________
Car:
Year: __________________________________
Make: _________________________________
Model: _________________________________
Engine: ________________________________
C.I. _________________
Payment Method (Circle one): Cash
Check Credit Card
Card Type (Circle one):
Visa Master Card
American Express Discover
Card Number: __________________ Expiration Date: ______ CCV
Code _____