Marysville Stages VRC Entry Form

Sponsor:

Competitor (CAR Owner):
Competitors Name (required): Surname First Name
Is the Competitor the Owner of the vehicle?

If no, what is the Owners Surname First Name
Competitors Address:
Suburb: Postcode:
Mobile Phone (required):
Email:
Competitors CAMS Licence Number (required) :
Competitors CAMS Licence Expiry Date (required): //

Driver Details:
Drivers Name (required):Surname First Name
Drivers Date of Birth (required): //
Address:
Suburb: Postcode:
Mobile Phone (required):
Email (required):
Drivers Grade (required):
Drivers Car Club (required):
Drivers Car Club Member Number (required):
Car Club Expiry Date (required): //
Drivers CAMS Licence Number (required) :
CAMS Licence Expiry Date (required): //
Drivers Civil Licence Number (required) :
Civil Licence Expiry Date (required): //
Driver full or provisional licence:
Event Driver Officiated at (required) :
Officialing Date (required): //
Drivers Emergency Contact (required):
Drivers Emergency Contact Phone Number (required):

Co-Driver Details:
Co Drivers Name (required):Surname First Name
Co-Drivers Date of Birth (required): //
Address:
Suburb: Postcode:
Mobile Phone (required):
Email:
Co-Drivers Grade (required):
Co-Drivers Car Club (required):
Co-Drivers Car Club Member Number (required):
Car Club Expiry Date (required): //
Co-Drivers CAMS Licence Number (required) :
CAMS Licence Expiry Date (required): //
Co-Drivers Civil Licence Number:
Civil Licence Expiry Date: //
Event Co-Driver Officiated at (required):
Officialing Date (required): //
Co-Drivers Emergency Contact (required):
Co-Drivers Emergency Contact Phone Number (required):

Vehicle Details:
Vehicle Make: Model: Year:
Nominal Engine Capacity: Reg. Number:
Colour:
Engine Number: Logbook Number:
Turbo:

Drive Configuration:

Class:

Scrutiny and Points
Scrutiny:

Have you registered for the OurAuto Excel Rally Series:

Service Crew
Service Crew 1 Contact(name):
Service Crew 1 Vehicle Make and Model:
Service Crew 1 Contact Number:

Service Crew 2 Contact(name):
Service Crew 2 Vehicle Make and Model:
Service Crew 2 Contact Number:

Entry Fee:
Please indicate your entry fee:

I would also like to enter the Spring 200 Half Marathon (additional fee of $100):

Payment:
Payment may be made by Direct Deposit details listed in Clause 6.7 of the Supplementary Regulations or via Cheque/Money Order or Cash. Event fees are set out in Clauses 6.4 a to d.
How will you be paying your entry fee(s):

Crews Understanding:

Signatures for the Competitor, Driver and Co-Driver and any Parent/Guardian Consent must be completed at Official Scrutiny or Event Documentation prior to the commencement of the event.

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