Competitor (Car Owner)
First name.
Surname
Date of Birth
/
Month
/
Day
Year
Date
Competition Licence No
Driver
First name.
Surname
Date of Birth
/
Month
/
Day
Year
Date
Competition Licence No
Car Driver Address
Street Address
Street Address Line 2
City
State
Postcode
Phone
Mobile
Work
Email Address
example@example.com
Next of Kin Name
Next of Kin Phone Number
Please enter a valid phone number.
Motorcycle Info
Make
Model
Passport/Log Book number
Year of Car
Capacity cc
Colour
Current Ambulance Service
Yes
No
Race or Ride day
Club
Preferred Number
Please provide actual or estimated lap times Pheasant Wood Circuit or other (please specify)
Passenger name
First name.
Surname
Date of Birth
/
Month
/
Day
Year
Date
Competition Licence No
Passenger's Address
Street Address
Street Address Line 2
City
State
Postcode
Phone Number
Mobile Number
Please enter a valid phone number.
Work
Next of Kin Contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Current Ambulance Service
Yes
No
Club
Please provide actual or estimated lap times Pheasant Wood Circuit or other (please specify)
Fees
Entry Fee $200.00
Same Driver 2nd Car $200.00
Regularity Entry $200.00
Cross Entry $200.00
FRI Practice $150.00
Note:
Timing Transponders are including in fee. $250.00 Fee is payable should you not return your Transponder on Sunday 12th September 2021. Race day events will not be timed.
Make Payments to:
Pheasant Wood Pty Ltd. ABN: 93 143 985 853
Card Type
Mastercard
Visa
Bankcard
Credit Card
Total Amount $
Expiry Date
Name on card
Signature
Date
-
Month
-
Day
Year
Date
For Cheque payment please complete (All Payments to be made to Pheasant Wood Pty Ltd)
Bank
Cheque Drawer
Cheque No
Entry Cheque
Bank Transfer Pheasant Wood Pty Ltd
Please use "All Historic & Surname" as reference.
BSB: 032 102 ACC: 108 676
Please use "All Historic & Surname" as reference.
Mail completed entry forms to:
Pheasant Wood Circuit Pty Ltd Po Box 20 MARULAN NSW 2579
Please provide some history of yourself and your machine for the circuit commentary.
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