INTERNATIONAL HOT ROD ASSOCIATION
300 Cleveland Road, Norwalk, Ohio 44857
Phone: 419-663-6666 Fax: 419-668-6601
2014 IHRA MEMBERSHIP, LICENSE & NUMBER APPLICATION
ALL COMPETITORS MUST HAVE COMPETITION LICENSE FORM ACCOMPANY
NEW APPLICATION – NO MATTER HOW FAST OR SLOW YOU RACE
O ET BRACKET MEMBERSHIP AND LICENSE: Please note: All Competitors must have Competition License Form
accompany this application. Includes *IHRA Insurance Program, Rule Book, 2 Decals, Membership and License Card, 1 Year
Subscription to Drag Review Magazine.
$60.00 one year ___________
$105.00 two years ________
$155.00 three years _____________
O MEMBERSHIP, LICENSE AND NUMBER (SUMMIT SUPERERIES, HR, SR, QR, TD, TS, STK, SS): Please note: All Competitors
must have Competition License Form accompany this application. Includes *IHRA Insurance Program, Rule Book, 2 Decals,
Membership and License Card, Number, 1 Year Subscription to Drag Review Magazine. United States and Puerto Rico
Add $10 per year for each additional class number needed.
$70.00 one year __________
$125.00 two years __________
$185.00 three years _____________
If running points at your track, request a Summit SuperSeries number:
Car Number __ X __ __ Track Name ___________________(You must declare track to be issued a number)
Top_____________________ Mod __________________ (must declare)
Class ________________
Permanent Number Requested _____________
$70.00 one year __________
$125.00 two years __________
$185.00 three years _____________
O Additional Number Requested _______
Class __________________
$10.00 per year
_______________
O CREW MEMBERSHIP AND FAN: Includes *IHRA Insurance Program, Rule Book, 2 Decals, Membership Card, 1Year
Subscription to Drag Review Magazine.
U.S. and Puerto Rico
$50.00 one year _______________
$85.00 two years _______________
$125.00 three years _____________
O Canadian and Mexico Members add $50.00 per year for postage to above fees $50.00 per year
O Foreign members add $70.00 per year for postage to above fees.
$75.00 per year
_______________
_______________
O ASSOCIATE MEMBERSHIP: Does not include Rule Book or Drag Review. Household must have a full member at the
same address. (Also select E.T. Bracket, Class Competition, or Crew/Fan above) subtract $10.00 per year ________
Full member Membership # ________________ and Expiration Date ______________
*INSURANCE VALID AT IHRA SANCTIONED EVENTS AT IHRA MEMBER TRACKS IN NORTH AMERICA ONLY.
TOTAL$
_______________
Name __________________________________________E-MAIL ADDRESS___________________________
Address _______________________________________________________ Phone _____________________________
City ____________________________________________ State _____________________ Zip ___________________
I AM ALSO AN NHRA MEMBER [ ] Yes
[ ] No
O Visa
O MasterCard
O Discover O AmEx
O Cash
O Check O Money Order
Credit Card # ____________________________________
Exp Date __________ Security Code __________
Print Name on Card ________________________________ Signature _________________________________
DRIVERS SIGNATURE: _____________________________________________________________________________________
"By signing this application, I certify that I have read and agree to abide by all the rules, regulations and agreements of the IHRA rulebook and related publications. I understand
that additions and amendments to the IHRA rulebook will appear online and in DRM throughout the year."
(Revised 01/01/14)
INTERNATIONAL HOT ROD ASSOCIATION
300 Cleveland Road, Norwalk, Ohio 44857
Phone: 419-663-6666 Fax: 419-668-6601
IHRA COMPETITION LICENSE FORM
(Each new applicant must enclose copy of valid state driver’s license, over and above a learner’s permit)
This Section To Be Filled Out By Competitor – Please Complete Legibly
LICENSE FEE: (see Membership, License and Number Application for explanation of fees). $10.00 fee if upgrade from current license.
O New
O Renewal
O Upgrade
O NHRA Transfer (Must enclose copy of NHRA License)
Car#______________ Class Applied For______________ IHRA Membership Exp. Date ________________
Name___________________________________________ Social Security Number _____________________
Address _________________________________________ Daytime Phone ____________________________
City _______________ State _______ Zip _____________ Evening Phone ____________________________
Date of Birth ____________________ Age ________
Occupation ________________________________
 Full Bodied Car
 Altered
 Dragster  Motorcycle
 Snowmobile
List of IHRA or ET Classes previously competed in: Class ___________ ET ___________ MPH ___________
Base Track _________________________________ Class ___________ ET ___________ MPH ___________
Other Tracks ________________________________ Class ___________ ET ___________ MPH ___________
I, the undersigned, do hereby understand the full provisions of the competitor’s license issued to me by the IHRA, and accept the responsibility of operating my
vehicle in a safe, sportsmanlike manner, and in accordance with all rules and regulations issued by the IHRA, and further, will accept any ruling by the IHRA
suspending my driver’s license rights in the event that I fail to strictly follow all of my responsibilities. I agree to abide by all rules, regulations and
requirements contained in the IHRA rulebook, related publications and any amendments issued by the IHRA subsequent to the issuance of my license. I hereby
agree and acknowledge that the Release and Waiver of Liability, Assumption of Risk, Indemnity and Rights Agreement which I have signed extends to all acts
of negligence or other wrongdoing by the Releasees, and is intended to be as broad and inclusive as is permitted under applicable law, and that if any portion
thereof is held invalid, it is agreed that the balance shall remain in full force and effect.
Date: ______________________ Driver’s Signature _______________________________________________
This Section To Be Filled Out By Track / Official and Licensed IHRA Competitors Only
This section not required for 11 sec or slower. 10-10.99 sec needs track official approval. Under 10 seconds requires passes.
(Current IHRA/NHRA License # ___________ Code ________ ) If NHRA transfer, passes not required.
(If passes are made on 1/8 mile track for Class B, you will receive a license restricted to 1/8 mile)
Facility Name ____________________________________________________________ O 1/4 Mile
O 1/8 Mile
1. 330”
E.T. ______
MPH _______
Track Official Witness ________________________________
2. Half Pass
E.T. ______
MPH _______
Track Official Witness ________________________________
3. Half Pass
E.T. ______
MPH _______
Track Official Witness ________________________________
4. Full Pass
E.T. ______
MPH _______
Track Official Witness ________________________________
5. Full Pass
E.T. ______
MPH _______
Track Official Witness ________________________________
This license is approved for one classification. Check the box to the left of the specific class.
CLASS
A
CATEGORY
 Top Fuel  Nitro Funny Car
 Pro Fuel
 Prostalgia Funny Car
 Funny Car
 Nitro Harley
 Pro Mod  Pro Stock
 Nostalgia Fuel Altered
B
C
D
E
M
 Top Sportsman
 Quick Rod
 Super Rod
 Hot Rod
 Motorcycle
 Top Dragster
 Super Stock
 Super Stock
 Stock
 Snowmobile
 ET Bracket
 ET Bracket
 ET Bracket
 ET Bracket
Date
_________
_________
_________
IHRA Licensed Driver Name
______________________________
______________________________
______________________________
IHRA Member #
____________
____________
____________
¼ Mile Times
iTimes reflect
0 – 7.99
8.00 – 8.99
9.00 – 10.99
11.00 Down
1/8 Mile Times
Classes to left
0 – 5.49
5.50 – 5.99
6.00 – 6.49
6.50 Down
Signature
___________________________________
___________________________________
___________________________________
Date Approved __________________ Approved By ________________________________________________________
IHRA OFFICIAL OR TRACK OFFICIAL ONLY
Revised 1/1/14
INTERNATIONAL HOT ROD ASSOCIATION
300 CLEVELAND ROAD
NORWALK, OHIO 44857
PHONE: 419-663-6666 FAX: 419-668-6601
MEDICAL PHYSICAL FORM
Name: ________________________________ Date of Birth: ________________________
Address: ____________________________________________________________________
City: _______________________________ State: _____________ Zip: ________________
Signature: _____________________________________ Date: _______________________
MEDICAL HISTORY
Y
N
HAVE YOU EVER HAD ANY OF THE FOLLOWING: (For each “yes” checked describe conditions in remarks)
CONDITION
Y
N
CONDITION
Y N
CONDITION
Y N
CONDITION
a. frequent or severe
headaches
b. dizziness or fainting
spells
c. unconsciousness for
any reason
d. eye trouble except
glasses
e. hay fever
f. asthma
g. heart trouble
h. high or low
blood pressure
i. stomach trouble
j. kidney stone or
blood in urine
k. sugar or
albumin in urine
l. epilepsy or fits
m. nervous trouble
of any sort
n. any drug or
narcotic habit
o. excessive
drinking habit
p. attempted
suicide
q. motion sickness
requiring drugs
r. military medical
discharge
s. medical rejection
from service
t. admission to
hospital
u. rejection for life
insurance
v. record of traffic
convictions
w. record of other
convictions
x. other illnesses
REMARKS: (if no changes since last report, so state) _______________________________________________
MEDICAL TREATMENT WITHIN THE PAST FIVE YEARS
Date
Name of Physician Consulted
_________________________________________________________________________
SIGNATURE OF APPLICANT
Reason
______________________________
DATE
APPLICANTS’ DECLARATION: I hereby certify that all statements and answers provided by me in this examination form are complete
and true to the best of my knowledge, and I agree that they are to be considered part of the basis for insurance of any IHRA certificate to
me.
REPORT OF MEDICAL EXAMINATION
NORMAL ABNORMAL CHECK EACH ITEM IN APPROPRIATE BOX
1. Head, face, neck and scalp
2. Nose
3. Sinuses
4. Mouth and throat
5. Ears, general (internal and external canals)
6. Ear Drums (perforation)
7. Eyes, general (visual activity under items 50 &51)
8. Ophthalmoscopic
9. Pupils (equality and reaction)
10. Ocular mobility (associated parallel movement, mystaginus)
11. Lungs and chest (including breasts)
12. Heart ( thrust, size, rhythm, sounds)
13. Vascular system
14. Abdomen and viscera (including hernia)
15. Anus and rectum (hemorrhoids, fistula, prostate)
16. Endocrine system
17. G-U system
18. Upper and lower extremities ( strength, range of motion)
19. Spine other musculoskeletal
20. Identifying body marks, scar, tattoos
21. Skin and lymphatic
22. Neuralgic (tendon reflexes, equilibrium, senses, coordination)
23. Psychiatric (specify any personality deviation)
24. General Systemic
[
Corrective lens required while driving
] NO * if previously
[ ] YES
“yes”, please include
explanation of change
FIELD OF VISION
[ ] Normal
[
LEFT EYE
Albumen
Systolic
URINALYSIS
Sugar
NEAR VISION
Right eye
20/
20/
Left eye
20/
20/
Both eyes
20/
20/
PULSE (Wrist)
BLOOD PRESSURE
Recumbent MM
Mercury
DISTANT VISION
BLOOD SUGAR TEST
(both fasting and 2 hour post prandial, required only if sugar is found in urine No S.I. Units))
FASTING
2-HOUR P.P.
HgA 1C
COMMENTS
FIELD OF VISION
RIGHT EYE
] Abnormal
NOTES: Describe every abnormality in
detail, enter applicable item number
before each comment. Use additional
sheets if necessary and attach to this
form.
Diastolic
Resting
After Exercise
ECG (Date)
OTHER TESTS
2 minutes after exercise
Req 55 or over
DISQUALIFYING DEFECTS/LIMITATIONS:
COMMENTS ON HISTORY AND FINDINGS:
APPLICANTS NAME:
FURTHER EVALUATION REQUIRED (EXPLAIN):
PHYSICALLY ACCEPTABLE
MEDICAL EXAMINER’S DECLARATION: I hereby cerify that I personally examined the applicant named on this medical examination repot, and that this report and
any attachment embodies my findings completely and correctly.
EXAMINATION DATE
MEDICAL EXAMINER’S NAME AND ADDRESS
MEDICAL EXAMINER’S SIGNATURE