Entry Form APX Suspension Blackbutt Rallysprint QRC 1

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Entry Form APX Suspension Blackbutt Rallysprint - QRC 1

“Held under the FIA International Sporting Code including Appendices and the National Competition Rules of Motorsport Australia.”
DRIVERS - COMPETITOR Details
DRIVER / COMPETITOR (Vehicle Owner)*
First Last
DRIVER - If not Vehicle Owner
First Last
DRIVER Address*
Street Address City State / Province / Region ZIP / Postal Code Country
DRIVER Email Address*
DRIVER Mobile Phone Number*
DRIVER Civil Licence Number*
DRIVER Civil Licence Expiry Date*
DRIVER Motorsport Australia Licence No*
DRIVER Motorsport Australia Licence Expiry Date*
DRIVER Member of Car Club*
DRIVER Car Club Membership No & Expiry Date
Year of Birth (if Medical Assistance is Required eg Ambulance)*
DRIVER Emergency Contact - Name and Phone No. - Not your Co-Driver - preferably someone not attending the event.*
Please inform your nominated emergency contact that you have nominated them as your emergency contact
Sponsor - Only one*
COMPETITOR DETAILS - Vehicle Owner (If Vehicle Driven by someone else) Name,Mobile and Email address
CO-DRIVERS Details
CO-DRIVER Name*
First Last
CO-DRIVER Address*
Street Address City State / Province / Region ZIP / Postal Code Country
CO-DRIVER Email Address*
CO-DRIVER Mobile Phone Number*
CO-DRIVER Civil Licence No*
CO-DRIVER Civil Licence Expiry Date*
CO-DRIVER Motorsport Australia Licence Number*
CO-DRIVER Motorsport Ausralia Licence Expiry Date*
CO-DRIVER Member of Car Club*
CO-DRIVER Car Club Membership No & Expiry Date*
Year of Birth (if Medical Assistance is Required eg Ambulance)*
CO-DRIVER Emergency Contact - Name & Phone No - Not your Driver - preferably someone not attending the event*
Please inform your nominated emergency contact that you have nominated them as your emergency contact
COMPETITOR'S Disclaimer
To View Disclaimer, Exclusion of Liability, Release and Assumption of Risk. Competitor and Competing Crew and or Service Crew in Rallies - go to: www.motorsport.org.au
DISCLAIMER to be signed and returned electronically*
- We agree to Read and Sign Disclaimer
Disclaimer will be emailed to you for signing by Driver, Co-Driver & Service Crew and returned electronically to Secretary
DESCRIPTION OF COMPETITIVE VEHICLE
Vehicle Year*
Vehicle Make and Model*
Chassis / Vin Number*
Vehicle Base Colour*
Vehicle Registration No*
Vehicle Registration Expiry Date*
Vehicle Log Book No*
QLD 3rd PARTY INSURANCE COMPANY (Name of Insurer)*
VEHICLE INFORMATION*
- N/A
- Letter of Authority to drive Vehicle - If not vehicle Owner Driver
- Rally Registration - copy of Authorisation to operate
EVENT Details
EVENT: I would like to compete in the following:*
- BSCC Winter Stages Event
Reconnaissance Saturday Morning*
- Yes
- No -
Optional Night Stage - Would like indication if interested (Not included in results )*
- Yes
- No
CLASS - I nominate to compete in the above vehicle in Class:*
- 4WD Vehicles
- Front Wheel Drive only Vehicles
- Rear Wheel Drive only Vehicles
DOCUMENTATION
DOCUMENTATION - as per Supplementary Regulations*
- I agree to forward ALL Documentation via Electronic means to Secretary
All Documentation has to be by ELECTRONIC Lodgement to Secretary, Judy Foster; judyfoster@y7mail.com
SCRUTINEERING
SCRUTINEERING - All vehicles to be Scrutineered as per Supplementary Regulations*
- Wynnum Future Auto, 8 Thorne St Wynnum - 0900 - 1200 hrs Sunday 21 July
- Regional Scrutiny South Burnett - Dave Jamieson Mob: 0429 631 331
- Regional Scrutiny Sunshine Coast - Victor Elias Mob: 0412 214 614
No Scrutiny will be held at Benarkin - unless organised with the Chief Scrutineer.
SERVICE CREW Details
Service Crew Chief -(1)
First Last
Service Crew Chief (1) - Mobile No
Service Crew Chief (1) Email
Service Crew Chief (1) Year of Birth (if Medical Assistance is Required eg Ambulance))
Service Crew Chief (1) Emergency Contact - Name & Phone Contact (Someone NOT attending the event)
Service Crew (2) Name
First Last
Service Crew (2) Mobile No:
Service Crew (2) Email
Service Crew (2) Year of Birth (if Medical Assistance is Required eg Ambulance))
Service Crew (2) Emergency Contact - Name and Phone Contact (Someone NOT attending the event)
Service Crew (3) Name
First Last
Service Crew (3) Mobile No:
Service Crew (3) Email
Service Crew (3) Year of Birth (if Medical Assistance is Required eg Ambulance))
Service Crew (3) Emergency Contact - Name and Phone Contact (Someone NOT attending the event)
Service Crew (4) Name
First Last
Service Crew (4) Mobile No:
Service Crew (4) Email
Service Crew (4) Year of Birth (if Medical Assistance is Required eg Ambulance))
Service Crew (4) Emergency Contact - Name and Phone Contact (Someone NOT attending the event)
TAX INVOICE - BSCC Winter Stages - Brisbane Sporting Car Club Ltd ABN: 18 010 180 266
Date*
DD slash MM slash YYYY
Tax Invoice to:*
Entry Fee Paid By:*
- Direct Deposit (EFT)
- Credit Card/PayPal
Entry Fee
Entry Fee - Direct Deposit
- $405.00 Entry Fee KCF Short Course (EFT - BSB: 084391 A/c: 508452534
- $20.00 Road Book
Entry Fee - Direct Deposit (EFT) BSB: 084 391 A/C 50845 2534
Entry Fee - Credit Card
- $415.00 Entry Fee Credit Card KCF Short Course
- $20.60 Road Book
Total
$ 0.00
Upload copy of EFT Payment
Max. file size: 128 MB.
Credit Card
Copy of Entry Form to go to: Email Address*
Please check your entry form before submission - if happy - hit the submit button
Thank you for your Entry The Organisers BSCC Winter Stages Brisbane Sporting Car Club Ltd

Brisbane Sporting Car Club

Brisbane Sporting Car Club is one of Queensland's oldest car clubs. The club has been 'Confederation of Australian Motorsport' Affiliated since 1954. BSCC hosts a variety of events at club level, multi-club and state championship rallies.

Phone
(07) 3267 7647
Mail
info@bscc.asn.au

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Entry Form APX Suspension Blackbutt Rallysprint - QRC 1

DRIVERS - COMPETITOR Details

CO-DRIVERS Details

COMPETITOR'S Disclaimer

DESCRIPTION OF COMPETITIVE VEHICLE

EVENT Details

DOCUMENTATION

SCRUTINEERING

SERVICE CREW Details

TAX INVOICE - BSCC Winter Stages - Brisbane Sporting Car Club Ltd ABN: 18 010 180 266

Please check your entry form before submission - if happy - hit the submit button