Full April Weekend / (tick one) / Late Fee Applies : 19th March / Closing Date: 29th March
Saturday 1st April 2017 / (tick one) / Late Fee Applies : 19th March / Closing Date: 29th March
Sunday 2nd April 2017 / (tick one) / Late Fee Applies : 20th March / Closing Date: 30th March
Held under the General Regulations of The Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and these Supplementary Regulations.
Please complete in BLOCK CAPITALS and submit one form per event
Entries can be submitted online at www.longton-dmc.co.uk
DRIVER INFORMATION
First Name / SurnameGender / Date of Birth *
Address
Town / County
Post Code / Email
Tel (day) / Mobile
Competition Licence No / Licence Type / Novice / Expert
(see SRs 4.1.19 for definition of a Novice)
Club(s) (Those relevant to this event)
VEHICLE INFORMATION
Manufacturer / Model / TypeYear / Vehicle Reg. No / OR / Not road-going (tick)
Capacity / cc / Engine (if applicable) / Turbo / Supercharged / Rotary
Fuel / Petrol / Methanol / Diesel / Other / Class
Shared Car? / Other driver’s name / Who drives first?
CHAMPIONSHIPS
Longton’s Northern Speed Championship / Others (Those relevant to this event)
OR / Longton’s Speed Series
LDMC Membership No
CONTACT IN CASE OF EMERGENCY (Must be Parent/Guardian for competitor under 18 years old)
Full Name / PhoneAddress / Post Code
Relationship to Driver
ENTRANT INFORMATION (if applicable)
First Name / SurnameCompany (if applicable)
Address
Post Code / Tel (day) / Mobile
Email / Entrants Licence No
PAYMENT (make cheques payable to LDMC)
Entry Fee - £135 per day or £250 for both days / £LDMC Membership Discount (£5 discount per day for LDMC Members) / £ / Less
Late Entry Fee £10 (If applicable as per SRs 4.1.21) / £ / Plus
Total / £
Signature * (Parent/Guardian if under 18 years old)