Entry Form
NZ Stadium Champs and Nationals Round 6
Racer Information
Please fill name and contact information
Drivers Name
*
Mr.
Mrs.
Miss.
Ms.
Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
-
Area Code
Phone Number
Competition Licence Number
*
ORANZ Licence Expiry Date
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Club Driver Belongs Too
*
DOB (if driver under 18 years of age)
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Transponder Details
*
If you don't have one and are hiring, put 123456
Next of Kin Details
*
First Name
Last Name
Next of Kin Phone Number
*
-
Area Code
Phone Number
Are you attending prizegiving?
*
Yes
No
If you are attending, how many people.
Additional Details
(To be completed in all cases if the Owner of the vehicle is other than the driver)
Owners Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owners Phone Number
-
Area Code
Phone Number
Vehicle Details
CC Capacity
*
Car Number
*
Vehicle Sponsors and online details if available (Website/Facebook page ETC ETC)
Please detail racing history for commentators and promotional material
Please Upload a Picture of Your Car We Can Use
Browse Files
Drag and drop files here
Choose a file
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of
Entry Fees
Select all that apply per entry. If you are entering more than one car you do a full form per car.
Entry Selections
*
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Adult Entry Fee
$250.00 NZD
$
250.00
NZD
Kiwi Trucks/Kids
$50.00 NZD
$
50.00
NZD
All payments are to be made to Canterbury Off Road Club
03 1593 0018939 00 please use your surname and car # for reference. You are not confirmed entered until you have paid, and we see it in our account, and you have entered.
Date Completed
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Print
Submit
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