2019 - 2020 500CC Khanacross - Event Entry Form

500 Car Club Khanacross Entry Form

Baskerville Raceway
Please select which Khanacross(s) will you would like to enter *

23rd February 2020
Entry Details (Competitor/Entrant)
Is the Competitor/Entrant the Same as the Driver 1? *

Yes No
Competitor Name *

CAMS Licence *

Licence No Expiry
Mobile No *
Email Address *
Entry Details (Driver 1)
Is driver 1 a Junior *
Driver 1 Name *

Driver 1 Address *

Street Address
Street Address Line 2
Suburb
Post Code	Country

Driver 1 Civil Licence

Licence No Expiry Date
Driver 1 CAMS Licence *

Licence No Expiry Date
Driver 1 Car Club *

Club Name Member No Expiry Date
Driver 1 Mobile *
Driver 1 E-mail *
Driver 1 Next of Kin *

Name Mobile Relationship
Is there a second Driver *

Yes No
Entry Details (Driver 2)
Is driver 2 a Junior *
Driver 2 Name *

Driver 2 Civil Licence

Licence No Expiry Date
Driver 2 CAMS Licence *

Licence No Expiry Date
Driver 2 Car Club *

Club Name Member No Expiry Date
Driver 2 Mobile *
Driver 2 E-mail *
Is Driver 2's Next of Kin the same as Driver 1 *

Yes No
Driver 2 Next of Kin *

Name Mobile Relationship
Is there a third Driver *

Yes No
Entry Details (Driver 3)
Is driver 3 a Junior? *
Driver 3 Name *

Driver 3 Civil Licence

Licence No Expiry Date
Driver 3 CAMS Licence *

Licence No Expiry Date
Driver 3 Car Club *

Club Name Member No Expiry Date
Driver 3 Mobile *
Driver 3 E-mail *
example@example.com
Is Driver 3's Next of Kin the same as Driver 1 *

Yes No
Driver 3 Next of Kin *

Name Mobile Relationship
Is there a fourth Driver *

Yes No
Entry Details (Driver 4)
Is driver 4 a Junior? *
Driver 4 Name *

Driver 4 Civil Licence

Licence No Expiry Date
Driver 4 CAMS Licence *

Licence No Expiry Date
Driver 4 Car Club *

Club Name Member No Expiry Date
Driver 4 Mobile *
Driver 4 E-mail *
example@example.com
Is Driver 4's Next of Kin the same as Driver 1 *

Yes No
Driver 4 Next of Kin *

Name Mobile Relationship

Vehicle Details
Make *
Model *
Colour *
Drive Type *

Front Wheel Drive Read Wheel Drive All Wheel Drive
Capacity *

Over 2000cc Under 2000cc

Entry Fee Payment Options
Payment via? *

PayPal / Credit Card EFT Point of Sale on the Day Cash on the day (additional $5)
Total Entry Fees Due
PayPal (Including Credit Cards

prev next ( X )
AUD Description
If you wish to pay by Credit Card, please select "Pay with a Card" at the PayPal Login Screen as shown below, otherwise log into PayPal as normal.
Payment Via EFT;

Electronic Funds Transfer Details:
Account Name: 500 Car Club of Tasmania
BSB: 067 002 Account No: 2801 2996

*please use Drivers surname as the reference

Form Submission

Details of the person submitting the form
Security Check *
Should be Empty: