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| Heart of Virginia Antique Car Show '99 - Registration Form |
| Name: _________________________________________________________________________ |
| Address: ______________________________________________ E-mail: ___________________ |
| Daytime Phone No.: ( ___ ) _________________ Evening Phone No.: ( ___ ) __________________ |
| Vehicle Registration: |
| Make: ____________________________ Year: ____________ Model: ______________________ |
| Make: ____________________________ Year: ____________ Model: ______________________ |
| Make Checks Payable to Heart Of Virginia Festival, P.O. Box 35, Farmville, VA 23901 |
| All registrants must sign below. Your signature waivers your right to any claim by you or other members of your party for damage, loss, or injury against the Heart Of Virginia Festival, or its individual members, as a results of participating in or traveling to or from this event. |
| SIGNED: ___________________________________________________ DATE: _____________ |
| Printed Name: ___________________________________________________________________ |