Email Address

Races or event entry fee(s) (Early Reg Amt) USAC Event only unless approved by BOD

Please include race/event date, race name & category(s) raced & Amt requested per race

Total $ Requested for Entry fees

$

Hotel Per Diem requested ($75 per night races >75 miles away)

Please reference race/event date, race name & nights stayed.

How many nights requested

Total $ Requested for Hotel Per Diem

Sorry, you gotta math here

$

Other $ Requested (subject to board approval)

Total $ Other

you gotta math here too

$

Total of all amounts requested (Entries + Per Diem + Other)

you gotta add all of it up and put it here

$

Can we Paypal this to you?

Paypal Address

Confirm Paypal Address

reimburse