NGK Victorian Khanacross Championship Entry Form

= required

Date: Sunday, 5th April 2020

CAMS Permit Number: 520/0504/01

CAR DETAILS

Make & Model
Class	Class A - Production Vehicles 0 to 1300cc Class B - Production Vehicles 1301cc to 1600cc Class C - Production Vehicles 1601cc to 2000cc Class D - Production Vehicles 2001cc to 3000cc Class E - Production Vehicles 3000cc and above Class G - Specials and 4WD/AWD Class J: Junior Class L: Ladies
Log Book Number (if applicable)
Car Number
Club Car	Yes No

COMPETITOR/ENTRANT DETAILS

Name
Address
Town/Suburb
State	- select - Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Post Code
Email Address
Phone Number
Club
Club Member Number
CAMS License Number
CAMS License Expiry Date
Emergency Contact Name
Emergency Contact Phone

DRIVER 1 DETAILS

Name
Category	Class A - Production Vehicles 0 to 1300cc Class B - Production Vehicles 1301cc to 1600cc Class C - Production Vehicles 1601cc to 2000cc Class D - Production Vehicles 2001cc to 3000cc Class E - Production Vehicles 3000cc and above Class G - Specials and 4WD/AWD Class J: Junior Class L: Ladies
Address
Town/Suburb
State	- select - Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Post Code
Email Address (if different to Competitor/Entrant)
Phone Number
Club
Club Member Number
CAMS License Number
CAMS License Expiry Date
Emergency Contact Name
Emergency Contact Phone
Supplementary Regulations	I have read and understand the Supplementary Regulations
Disclaimer Understanding	I have read, understood, acknowledge and agree to the risk warning disclaimer and indemnity document including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity. (This document is on the website with the supplementary regulations).
Payment Method	Online - via EFT (please bring copy of your receipt to Documentation) Cheque/Money Order - via Post Cash - to the Event Secretary on the day of the event

DRIVER 2 DETAILS

Add 2nd Driver	Yes No
2nd Driver Name
2nd Driver Category	Class A - Production Vehicles 0 to 1300cc Class B - Production Vehicles 1301cc to 1600cc Class C - Production Vehicles 1601cc to 2000cc Class D - Production Vehicles 2001cc to 3000cc Class E - Production Vehicles 3000cc and above Class G - Specials and 4WD/AWD Class J: Junior Class L: Ladies
2nd Driver Address
Town/Suburb
State	- select - Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Post Code
2nd Driver Email Address
2nd Driver Phone Number
2nd Driver Club
2nd Driver Club Member Number
2nd Driver CAMS License Number
2nd Driver CAMS License Expiry Date
2nd Driver Emergency Contact Name
2nd Driver Emergency Contact Phone
2nd Driver Supplementary Regulations	I have read and understand the Supplementary Regulations
2nd Driver Disclaimer Understanding	I have read, understood, acknowledge and agree to the risk warning disclaimer and indemnity document including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity. (This document is on the website with the supplementary regulations).
2nd Driver Payment Method	Online - via EFT (please bring copy of your receipt to Documentation) Cheque/Money Order - via Post Cash - to the Event Secretary on the day of the event

DRIVER 3 DETAILS

Add 3rd Driver	Yes No
3rd Driver Name
3rd Driver Category	Class A - Production Vehicles 0 to 1300cc Class B - Production Vehicles 1301cc to 1600cc Class C - Production Vehicles 1601cc to 2000cc Class D - Production Vehicles 2001cc to 3000cc Class E - Production Vehicles 3000cc and above Class G - Specials and 4WD/AWD Class J: Junior Class L: Ladies
3rd Driver Address
Town/Suburb
State	- select - Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Post Code	- select - Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
3rd Driver Email Address
3rd Driver Phone Number
3rd Driver Club
3rd Driver Club Member Number
3rd Driver CAMS Member Number
3rd Driver CAMS License Expiry Date
3rd Driver Emergency Contact Name
3rd Driver Emergency Contact Phone
3rd Driver Supplementary Regulations	I have read and understood the Supplementary Regulations
3rd Driver Disclaimer Understanding	I have read, understood, acknowledge and agree to the risk warning disclaimer and indemnity document including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity. (This document is on the website with the supplementary regulations).
3rd Driver Payment Method	Online - via EFT (please bring copy of your receipt to Documentation) Cheque/Money Order - via Post Cash - to the Event Secretary on the day of the event

DRIVER 4 DETAILS

Add 4th Driver	Yes No
4th Driver Name
4th Driver Category	Class A - Production Vehicles 0 to 1300cc Class B - Production Vehicles 1301cc to 1600cc Class C - Production Vehicles 1601cc to 2000cc Class D - Production Vehicles 2001cc to 3000cc Class E - Production Vehicles 3000cc and above Class G - Specials and 4WD/AWD Class J: Junior Class L: Ladies
4th Driver Address
Town/Suburb
State	- select - Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Post Code
4th Driver Email Address
4th Driver Phone Number
4th Driver Club
4th Driver Club Member Number
4th Driver CAMS License Number
4th Driver CAMS License Expiry Date
4th Driver Emergency Contact Name
4th Driver Emergency Contact Phone
4th Driver Supplementary Regulations	I have read and understand the Supplementary Regulations
4th Driver Disclaimer Understanding	I have read, understood, acknowledge and agree to the risk warning disclaimer and indemnity document including the exclusion of statutory guarantees, warning, assumption of risk, release and indemnity. (This document is on the website with the supplementary regulations).
4th Driver Payment Method	Online - via EFT (please bring copy of your receipt to Documentation) Cheque/Money Order - via Post Cash - to the Event Secretary on the day of the event
	SUBMIT ENTRY