Nomination Form Event *2021 Australian 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 Modified Ladies Outlaw 125cc Non Gear Box 125cc Pro 200cc Twin 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$40 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 * DINNER: Dinner Tickets Adults $30 Kids Under 10-14 $10 Kids under 10 Free Dinner AdultNumber of adults Children 10-14Number of Children 10-14 Children Under 10Number of Children Under 10 Nomination PriceTransponder Hire PriceDinner PriceTotal OwedNomination 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 Submit