USAC Discount Program Submission

USAC DISCOUNT PROGRAM REGISTRATION

COACH OR RIDER

COACHRIDER

COACH/RIDER FIRST NAME:*

COACH/RIDER LAST NAME:*

ADDRESS LINE 1: (Street Address, P.O. Box)*

ADDRESS LINE 2: (Optional Apt., Unit, Ste. #)

TOWN OR CITY:*

STATE/PROVINCE/REGION:*

ZIP/ POSTAL CODE:*

COUNTRY:*

PHONE NUMBER:*

DATE OF BIRTH

GENDER

MaleFemale

EMAIL ADDRESS:*

SOCIAL MEDIA HANDLE

INTENSE DEALER NAME

CLUBS/TEAM NAME

USAC ID#

UPLOAD USAC MEMBERSHIP CARD

PDF or JPG files only keep files under 5MB

USAC EXPIRATION DATE

Signature of Applicant (or Parent/Legal Guardian if under 18 years of age)

Write Name Above. *Note by writing in name you are agreeing to the rules and regulations and verify you are the parent or legal guardian of the registrant.