DRIVERS ONLY

Hoosier Park Purse Distribution Request Form

I would like the purse distributed in the following manner: Pick Up or   Mailed

If you have checked "Pick Up", and you would like someone other then yourself to pick up the check(s), please print their name(s) here:

Name:   Name:

YOUR MAILING ADDRESS:

Name:

Street Address:

City:   State:   Zip Code:

NOTE: If, at any time, you have an address change, you must complete a new Purse Distribution Form, with the new information.

***** PLEASE FILL OUT ALL INFORMATION BELOW *****

Name:
 		 Daytime Phone Number:
 
Signature: ______________________________
 		 Social Security Number:
 
Date: IHRC # USTA #

Print Purse Distribution Request Form, Sign, and Submit to:
Hoosier Park at Anderson
4500 Dan Patch Circle
Anderson, IN  46013
c/o Horsemen's Bookkeeper

FOR OFFICE USE ONLY --- DO NOT WRITE BELOW THIS LINE