Historic Sports & Racing Car Association of NSW Inc

Historic Sports & Racing Car Association of NSW Inc

ENTRY FORM

All Historic Summer Meeting

WakefieldPark

Saturday 25th & Sunday 26thFebruary 2012

CAMS Permit #

Held under the International Sporting Code of the FIA and the National Competition Rules of CAMS

Driver:(Please indicate the Driver of the entered vehicle)Office Use:

Name:

/ Date of Birth:

Address:

/ Ph Home:
/ Ph Work:
Email: / Ph Mob:
Emergency Contact: / Emergency Ph:
CAMS Licence No: / Grade
HSRCA Regularity Licence: / Club:(for race programme)

Competitor:(Please indicate the Owner of the entered vehicle if not driver shown above)

Name: / Competitor’s CAMS Licence No:

Vehicle: (Please indicate details for the entered vehicle)

Make: / Model: / Year:
Capacity: / Colour: / Group: / Valves per Cylinder
CAMS Log Book: / CofD No.: / Dorian No:
Preferred Car No: / 2nd Pref: / 3rd Pref: / Alcohol Fuel? / Yes / No

The Fees for the Meeting (Racing & Regularity) include GST and are as follows:

Race or Regularity Meeting Entry Fee – / $300 / $ ……………..
Cross Entry into another category (same car, second driver) / $300 / $ ……………..
Cross Entry into another category (same or second car, same driver) / $150 / $ ……………..
Carport $100 (If interstate M&O requiring carport, please write “free”) / $100 / $ ……………..
Less $100 rebate from Eastern Creek November 2011 (not Group S) / Less $100 / $ (…………)
Your HSRCA Member Discount – Member No……………… / Less $20 / $ (…………)
Payment by Direct Debit: BSB: 062 205 Account No.1000 7952 Ref:
Payment by Credit Card (Mastercard, Bankcard or Visa only) or cheque.Note: A service fee of 3% will be added to all credit card transactions.Total / $ ……………..
Expiry …….…/…………..
…………………………………………………..……………………………………………………..
Name on CardSignature of card holder

Tax Invoice for HSRCA of NSW Inc ABN Number: 58 251 017 401