2019 LWE Mt Stages Rally Entry Form

1

Is the Competitor/Entrant the Same as the Driver?* This field is required.

YESNO

2

Competitor Name* This field is required.

First Name

Last Name

Email Address

Mobile Number

3

Competitor Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

4

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

5

Entry Details - Driver* This field is required.

First Name

Last Name

Email Address

Mobile Number

6

Driver Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Driver Club Membership

Motor Sports Club of Tasmania

North West Car Club

500 Car Club

8

Driver Club Membership - Other* This field is required.Please list your club membership

9

Driver CAMS Licence Type

10

Driver CAMS Licence Number

11

Driver CAMS Licence Expiry

Date

12

Driver Civil Licence Number

13

Driver Civil Licence Expiry

Date

14

Driver Next of Kin

Name

Relationship

Mobile Number

15

Entry Details - Co Driver* This field is required.

First Name

Last Name

Email Address

Mobile Number

16

Co Driver Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

17

Co Driver Club Membership

Motor Sports Club of Tasmania

North West Car Club

500 Car Club

18

Co Driver Club Membership - Other* This field is required.Please list your club membership

19

Co Driver CAMS Licence Type

20

Co Driver CAMS Licence Number

21

Co Driver CAMS Licence Expiry

Date

22

Does the Co Driver have a Current Civil Drivers Licence* This field is required.

YESNO

23

If the Co Driver does not have a valid or current Civil Drivers Licence, please download and complete this declaration and present at the time of documentation. (Right Click and Save As)

24

Co Driver Civil Licence Number

25

Co Driver Civil Licence Expiry

Date

26

Co Driver Next of Kin

Name

Relationship

Mobile Number

27

Sponsor Name(s)

28

Competition Vehicle Details* This field is required.

Make

Model

Year

Colour

Registration Number

Registration Expiry

29

Vehicle Colour and Signwriting* This field is required.

Base Colour

Signwriting and other colours

30

Competition Category Details* This field is required.Choose one or many categories below

TRC Class

31

Will you be utilising another competitors service crew* This field is required.(you won't be bringing your own service crew)

YESNO

32

Please specify Other Competitor / Driver / Team* This field is required.

33

Service Crew Chief

First Name

Last Name

Email Address

Mobile Number

34

Service Crew MembersDetail for crew members 1 to 4

Name

Mobile Number

Name

Mobile Number

Name

Mobile Number

Name

Mobile Number

35

This form was submitted by* This field is required.Details of the person submitting the form

First Name

Last Name

Please enter your email

36

Thank you for your entry to the 2019 LWE Mt Stages Rally!

As we draw closer to the event, we will update you with any bulletins and further information as it comes to hand.