Nomination Form Event *2022 SKAA Queensland Speedway Kart TitleName * First Name Last Name Date of Birthdd/mm/yyyyAddress Street Address * Address Line 2 State / Province / Region * Country * Post Code * Mobile Phone *Email *Speedway Australia # *SKAA Log Book # *Select Divisions * Sub Junior Juniors Junior Standard Standard Standard Heavy Ladies Modified Outlaw 125cc GB 125cc NGB Provide Kart(s) Numbers *Please include which section each kart number belongs to if applicable. For example: Standard Speedway Kart - NT#24Provide Transponder Number(s)Please include the kart number each transponder is allocated to. For example (#26 - 185261)Transponder Hire$20 per Transponder Hire File Uploads20mb 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 * Nomination PriceTransponder Hire Price Total OwedNOMINATION FEES: $100 for seniors $80 juniors $60 per extra division Late entries $200 per class This fee includes complex and pit entry for driver only. Nomination fees must be paid and received with nomination form by Saturday 18th June 2022 along with copies from your SKAA Log Book showing Front Cover and proof of at least two SKAA Club meetings within the 12 months from close of nomination date. Account Name; Cairns Speedway Karts – BSB 064-830 Account Number 10508632 When paying nominations please us QT Name and Class as Reference. (eg QT John Smith) Submit