Contingency Claim Form
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1
22015 CONTINGENCY CLAIM FORM
You must complete this form and return it to the sanctioning club BEFORE THE RACE TAKES
Section 1.
RIDER
PLACE. No retroactive claim forms will be considered. Complete in Full - MUST PRINT.
Any form that is not legible or not fully completed with all rider info will not be processed.
Name:
Date:
Competition #:
Street:
Postal
Check box if new
Code:
City & Prov:
address:
[
]
(
)
Classes Entered:
Phone:
1.
2.
Social Security #:
3.
Rider Signature:
4.
5.
11” Fairing
Section 2.
Dunlop
Fork
Dunlop
TECH INSPECTION
Decals (2)
Front/Rear
Decals (2)
Patch
Class
1.
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2.
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3.
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4.
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5.
[
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Date:
Certified By:
Section 3.
SANCTIONING CLUB
Complete in Full Before Sending to Dunlop.
Finish
Race Date:
/
/
Class
1.
Location:
2.
3.
Club Signature:
Track:
4.
Date:
5.
Section 4.
TO BE COMPLETED BY DUNLOP TIRE CORPORATION
Award:
$
Certificate
Dunlop Initials:
Date Submitted:
CLUB
Mail all forms to: Cori Maynard – M/C Division
Dunlop Tire Corp.
P.O. Box 1109
Buffalo, NY 14240
MUST Include Official Results (Required to Process Claim Forms)
Note: Rider/Tech/Club
No certificates will be issued unless all information is provided
.
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