EmailMe Form - LaSalle Speedway Credential Request

Event Requesting *

Event Date *

MM / DD / YYYY

Please Select One *

Photographer

Reporter

Other

Please Select One *

Magazine

Newspaper

Radio

Other

Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country

Phone *

### - ### - ####

Cell Phone

### - ### - ####

Email *

Affiliation/Organization *

Supervisor Contact Name/Number

Web Site Address

Fax Number

### - ### - ####

Acknowledgement *

I have read and agree to the terms and conditions outlined below

Any Photographer receiving credentials must provide a Disc or Copy of all photos to the LaSalle Speedway. In addition I grant the LaSalle Speedway permission to use my photographs in any/all publications. This is to include but not limited to web site, promotional materials, advertising material etc. without compensation or any other consideration perpetuity. I also hereby authorize LaSalle Speedway to edit, alter, copy, exhibit, publish, or distribute these photographs. I agree not to sell these photographs or any other items at/on LaSalle Speedway property.