NAME:
ADDRESS:
EMAIL:
example@example.com
MOBILE:
Format: (000) 000-0000.
BANK DETAILS:BSB:
ACCOUNT #:
ACCOUNT NAME:
MEMBERSHIP TYPE
*
$200 Series membership (if not made upfront payment will be deducted from tow money after first round)
PAYMENT TO: SUPER SEDANS NSW BSB# 082-744 ACC#160942566 SURNAME AS REFERENCE
CAR NUMBER:
CAR TYPE:
SPONSORS:
TRANSPONDER NUMBER:
*
WRITE 'NO' IF YOU DO NOT HAVE A TRANSPONDER OTHERWISE ADD TRANSPONDER NUMBER
SPEEDWAY AUSTRALIA LIC NUMBER:
EXP:
SIGNATURE:
DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: