Dirt Dollars Contingency Awards Application

Dirt Dollars Contingency Awards Application

Please provide the following information only for your initial application. This form only needs to be submitted once, as a separate form is used to submit each win for the Dirt Dollars credit. Upload photos of your car showing the Speedwerx headers installed and our decals or logos on each side of the car if you already have them. If you do not have the logos on the car yet, check the boxes to have decals sent to you. Once you have logos on the car, those photos may be provided with the first win submission. *Please Note: We will temporarily waive the requirement to have decals on the car if you register first and then get a win in the few days before the decals arrive- we just ask you share our Weekly Winners Facebook post and tag us on your official page. Any wins before you have decals on the car will otherwise not be eligible for credit.*
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
ex: email@gmail.com
Car Owner (or Driver Name if owner is listed above)
Race Team Name
Race Team Website
ex: www.speedwerx.com
Race Team Facebook Page*
ex: www.facebook.com/speedwerx
Car Number / Sanction or Series / Class*
Chassis Builder*
Engine Builder*
Speedwerx Dealer*
Purchase Date / Invoice Number / Total Amount
Check to have Speedwerx Decals sent to you *Please Note: We will temporarily waive the requirement to have decals on the car if you register first and then get a win in the few days before the decals arrive- we just ask you share our Weekly Winners Facebook post and tag us on your official page. Any wins before you have decals on the car will otherwise not be eligible for credit.*
Upload Current Photo Showing Speedwerx Headers Installed

Upload a File
Max File Size 2mb Cancelof
Upload Left and Right Side Photos if you already have Speedwerx Decals Installed

Upload a File
Max File Size 2mb Cancelof
Upload a File
Max File Size 2mb Cancelof
How did you hear about Speedwerx or the Dirt Dollars Program?*
Please Specify*
Additional Comments
Enter the message as it's shown*
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