Nomination Form

Event *

Name *

First Name

Last Name

Date of Birth

dd/mm/yyyy

Address

Street Address *

Address Line 2

State / Province / Region *

Country *

Post Code *

Mobile Phone *

Email *

Speedway Australia # *

SKAA Log Book # *

Select Divisions *

Provide Kart(s) Numbers *

Please include which section each kart number belongs to if applicable. For example: Standard Speedway Kart - NT#24

Provide Transponder Number(s)

Please include the kart number each transponder is allocated to. For example (#26 - 185261)

Transponder Hire

$40 per Transponder

Hire

File Uploads

20mb per file MAX pdf,docx,doc,jpg,jpeg,png file types only

Valid Licence

File name:

File size:

Log Book Entry #1

File name:

File size:

Log Book Entry #2

File name:

File size:

Indemnification *

By checking this box you accept the following indemnification: This entry will be accepted only on the condition that the vehicle entered, the owner, the driver therefore any other person connected with the said vehicle whilst participating in the above mentioned contest do so at their own risk. The entrant, driver or any person connected with the vehicle entered shall have no claim against any of the organisers or the people acting on behalf of the organisers or promoters for any loss, damage or injury to them in the said contest or surrounds. I acknowledge and understand and will abide with the Speedway Australia racing rules and those set out in this nomination form and its attachments.

I Accept

Supplementary Regulations *

I Accept that I have read, understood and agree to adhered to the supplementary regulations of this event.

I Accept

Next of Kin

Name *

First Name

Last Name

Relationship *

Phone *

Address

Street Address *

Address Line 2

State / Province / Region *

Country *

Post Code *

DINNER:
Dinner Tickets
Adults $30
Kids Under 10-14 $10
Kids under 10 Free

Dinner

Adult

Number of adults

Children 10-14

Number of Children 10-14

Children Under 10

Number of Children Under 10

Nomination Price

Transponder Hire Price

Dinner Price

Total Owed

Nomination Fee & BBQ must be paid within the next 3 days via EFT to
Bank Details for Direct Deposit
SKAA
Bendigo Bank
BSB 633 000
A/C 144280906