500CC - Navigation Assembly - Event Entry Form

Which event do you wish to enter*

27th October - Presidents Trial
1. Entry Details (Competitor/Entrant)
Is the Competitor/Entrant the Same as the Driver 1?*

YesNo
Competitor Name
CAMS Licence

Licence NoExpiry
Mobile No
Email Address
Address

Street Address

Street Address Line 2

CityState

Post Code
2. Entry Details (Driver 1)
Driver 1 Name*
Civil Licence*

Licence NoExpiry Date
CAMS Licence*

Licence NoExpiry Date
Car Club

Club NameMember NoExpiry Date
Mobile*
E-mail*
Address

Street Address

Street Address Line 2

CityState

Post Code
Next of Kin*

NameMobileRelationship
3. Entry Details (Driver 2)
Driver 2 Name*
Civil Licence

Licence NoExpiry Date
CAMS Licence

Licence NoExpiry Date
Car Club

Club NameMember NoExpiry Date
Mobile
E-mail
Address

Street Address

Street Address Line 2

CityState

Post Code
Next of Kin*

NameMobileRelationship
4. Vehicle Details
Vehicle*

MakeModelYear
Registration

Registration NoExpiry Date
5. Entry Fees
Options*
prevnext( X )
Navigation Assembly Entry Fee$80.00AUD

Total $0.00AUD
6. Payment Options
Payment via?*

EFTCheque/Money OrderPayPal / Credit Card
Payment Via EFT;

BSB: 067-003

ACC: 28063934

Account Name: 500 Car Club of Tasmania

*please use Drivers surname as the reference
Payment via cheque/Money Order;

All cheques and money orders should be made out to the 500 Car Club of Tasmania

170 Nierinna Road

MARGATE 7054
Payment via PayPal / Credit Card;

Pease click HERE to complete your payment

(After Payment, don't forget to return to this TAB to complete your entry!)
7. Form Submission

Details of the person submitting the form
Submitted by*

First NameLast Name
Submitter Email*
example@example.com
Security Check*
Should be Empty:

1. Entry Details (Competitor/Entrant)

2. Entry Details (Driver 1)

3. Entry Details (Driver 2)

4. Vehicle Details

5. Entry Fees

6. Payment Options

7. Form Submission