2023 Pro Rally Camcrusher Intro Entry Form

2023 Pro Rally Camcrusher Intro Trial Entry Form
While you're encouraged to complete as much of this form as possible, to submit an entry to be considered for acceptance you need to, at a minimum:
- provide your information and contact details
- provide information about the Competitor
- provide information about the Driver
- submit this entry form
- pay your entry fee
After your intial submission, you will be able to re-open, update and resubmit this entry form to complete it. The email confirming your submission will include a link that lets you re-open the form.

Entry forms will be closed on 27 October 2023.

All required information must be provided and all required documents must be uploaded by that date.
Competitor
Competitor:

First NameLast Name
Is the Competitor the owner of the vehicle?
Competitor's address:

Street Address

Street Address Line 2

CityState

Postcode
Competitor's email:
example@example.com
Competitor's phone (mobile preferred):
Please enter a valid phone number.Format: (000) 000-0000.
Competitor's MA Licence:
Competitor's MA Licence Expiry:

DayMonthYear
Date
Driver
Driver:

First NameLast Name
Driver's address:

Street Address

Street Address Line 2

CityState

Postcode
Driver's email:
example@example.com
Driver's phone (mobile preferred):
Please enter a valid phone number.Format: (000) 000-0000.
Driver's Birth Date

DayMonthYear
Driver's Emergency Contact:

First NameLast Name
Driver's Emergency Contact phone (mobile preferred):
Please enter a valid phone number.Format: (000) 000-0000.
Driver's MA Licence:
Driver's MA Licence Expiry:

DayMonthYear
Date
Driver's Civil Licence:
Driver's Civil Licence Expiry:

DayMonthYear
Date
Driver's Car Club:
Driver's Car Club Number:
Driver's Car Club Expiry:

DayMonthYear
Date
Driver's Grade
Co-Driver
Co-Driver:

First NameLast Name
Co-Driver's address:

Street Address

Street Address Line 2

CityState

Postcode
Co-Driver's email:
example@example.com
Co-Driver's phone (mobile preferred):
Please enter a valid phone number.Format: (000) 000-0000.
Co-Driver's Birth Date

DayMonthYear
Co-Driver's Emergency Contact:

First NameLast Name
Co-Driver's Emergency Contact phone (mobile preferred):
Please enter a valid phone number.Format: (000) 000-0000.
Co-Driver's MA Licence:
Co-Driver's MA Licence Expiry:

DayMonthYear
Date
Co-Driver's Civil Licence:
Co-Driver's Civil Licence Expiry:

DayMonthYear
Date
Co-Driver's Car Club:
Co-Driver's Car Club Number:
Co-Driver's Car Club Expiry:

DayMonthYear
Date
Co-Driver's Grade
Vehicle Details
Make:
Model:
Reg No:
Nominal Capacity:
Colour:
Year:
Turbo
Engine Number:
Drive Train:
MA Logbook Number:
Scrutiny
Scrutiny attendance?
If you are doing Regional Scrutiny what is the Scrutineer's name and licence number?
Service Crew 1
Service Crew 1 Vehicle Make:
Service Crew 1 Vehicle Model:
Service Crew 1 Vehicle Reg No:
Service Crew 1 Vehicle Year:
Service Crew 1 Vehicle Colour:
Service Crew 1 Person in Charge:

First NameLast Name
Service Crew 1 Contact phone (mobile preferred):
Please enter a valid phone number.Format: (000) 000-0000.
File Upload

Cancelof
Entry Fee
Total Due:
The entry fee includes:
- A full set of Road Books
- The RallySafe vehicle tracking unit hiring fee, excluding fitting kit
- Service vehicle registrations.
Payment of Entry Fees:

Payment of entry fees may be made via the following methods:
a)   EFT (Electronic Funds Transfer). In the “payment description” field please use the three-letter event code “CIR” followed by the drivers’ surname e.g. CIR ROBERTS

EFT Details:    Account name: FORD FOUR CAR CLUB

                                           BSB:                  033 065

                                           Account:           392 296

b)    Credit card facility available on the entry form. A provider fee will be added to credit card transactions.
On submission, you will receive email acknowledgement and a pdf record of what you have submitted.
The email includes a link to allow you to re-open, update and resubmit this form. Use the same link
each time you want to update your entry submission.
Thank you for your submission!
Should be Empty:

2023 Pro Rally Camcrusher Intro Trial Entry Form

Competitor

Driver

Co-Driver

Vehicle Details

Scrutiny

Service Crew 1

Entry Fee