CC Logo2017 CHARITY CHALLENGE REGISTRATION

Online registration is now open. Please complete the form below and click Submit Registration at the bottom of the page. If you need to reset your information, click the Reset All Fields button.

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REGISTRATION INFORMATION

First Name:

Last Name:

Name as it should appear on Name Badge:

Address:

City / Town:

State:

Zip:

Phone:

Email Address:

Employer / Retired:

Employer Address:

City / Town:

State:

Zip:

Choose a Class:

Would you like to help judge (1/2 day)? Yes  No

Are you retired from driving? Yes  No

Are you a member of your company's Management Team? Yes  No

Are you part of a Father / Son / Daughter team? Yes  No

If so, other half of team:

More than one sibling? List other siblings:

 

DRIVER INFORMATION

The following information will be announced when you are entering the course. As time is limited, please summarize your information.

How many years have you been in the trucking industry?

How many accident free miles / years do you have?

Spouse / Significant Other:

Children:

Hobbies:

Have you competed in previous Charity Challenges? Yes  No

Summarize your Trucking Awards and Citations:

Summarize you your previous Competition Information (Company, State, National, Charity):

   

 

 

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Northeast Professional Truck Drivers Charity Challenge

167 D Street, Lowell MA 01851-4345

necharitychallenge@gmail.com | 781.469.5988 | www.necharitychallenge.org