California Highway Pantera’s

Of the Inland Empire

 

PROUDLY PRESENTS THE 2004

Las Vegas Fremont Street Display

Entry Form – Please Print!

 

Owner _________________________________________________________________________

 

Address________________________City__________________State__________Zip__________                                                     

 

Day Phone (       )_____________________Evening Phone (       )__________________________

 

E-Mail Address__________________________________________________________________

               

Vehicle Year___________Make_____________________Model___________________________

 

Chapter Affiliation________________________________________________________________

 

Applicant is entitled to one T-Shirt for each vehicle entered in the display.  Please indicate size below.

 

T-Shirt Size:                           q Medium                                          q Extra Large

                                                q Large                                             q 2XL

                                               

Please submit a photograph of your entry, which may be used for promotional purposes.  An application fee of $15.00 is required with this form for each vehicle submitted by April 11, 2004.  Please make checks payable to CHPIE and remit to CHPIE, c/o Tom Knowles, 1812 Glen Way, La Verne, CA 91750.  Any questions, call Tom at (909) 593-0669.

 

  In consideration of participation by the undersigned in the Fremont Street Display to be held on Fremont Street, Las Vegas, Nevada on April 24, 2004, the undersigned agrees to indemnify and hold harmless The City of Las Vegas, California Highway Panteras of Inland Empire, Las Vegas Fun Rally Committee, Pantera Owners Club of America, and the Fremont Street Experience Corporation and their members, officers, agents, servants, employees, and assigns, against and from claims, demands, losses, costs, damages, suits, judgments, penalties, expenses or liability of any kind whatsoever arising directly or indirectly out of or in connection with my participation in the event, and I further release and discharge each of the persons and entities referred to herein of and from any and all known claims, demands, losses and/or liabilities of any kind or nature resulting from any act of any person whatsoever.

 

Signature  ____________________________________________Date_____/____/_______

                                    Owner or agent

 

Enclosed is a check in the amount of $__________________ for_________vehicles(s)