MG CAR CLUB OF TASMANIA INC Preferred No Assigned No Class Paid ABN 42 028 552 599 ENTRY FORM GPO Box 5 Hobart Tasmania 7001 Competitor Use Club Use Only Club Use Only Club Use Only Only (Legal Owner of the car) Baskerville Supersprints 22th April 2018 Entry Fee; $110.00 individual $150.00 Family (2) $30.00 additional Family member COMPETITOR DRIVER NAME (IN FULL) NAME (IN FULL) ADDRESS ADDRESS CAMS AFFILIATED CLUB CAMS AFFILIATED CLUB MEMBER NUMBER MEMBER NUMBER CAMS LICENCE NO. CAMS LICENCE NO. DATE OF BIRTH DATE OF BIRTH EMAIL ADDRESS Please indicate your permission, or otherwise, for notification of future events run by MGCCT by email: Yes, I wished to be notified No, I don’t wish to be notified DESCRIPTION OF VEHICLE MAKE MODEL BODY TYPE YEAR ENGINE CAPACITY TURBO or S/C Yes No FEE CASH CHEQUE MONEY ORDER AMOUNT $ CHARGE MY VISA MASTERCARD AMOUNT $ CARD CARD AMOUNT $ No EXPIRY CARD HOLDER’S SIGNATURE OF CARD HOLDER NAME SCRUTINY REPORT (CLUB USE ONLY) SPEED EVENTS 1 17 MOTORKHANA 9 17 ONLY – – Yes No Yes No □ □ □ □ 1 Safety helmet (AS 1698) 9 Brakes □ □ □ □ 2 Drivers apparel 10 Steering Fire extinguisher (900gm min)) □ □ □ □ 3 11 Accelerator linkage CERTIFICATION Seat belts Condition – □ □ □ □ 4 12 Fluid leaks oil, water, brake fluid Comply Aust. Standards (AS 2596, E35) □ □ □ □ 5 Bonnet (non extensible) 13 Suspension □ □ □ □ 6 Tail strap 14 Wheels and □ □ □ □ 7 Blue triangle 15 Fuel □ □ □ □ 16 Battery 8 Brake lights □ □ 17 Video camera Specify any other faults or relevant information PASSED NOT PASSED COMPETITOR DISCLAIMER SIGNED: PTO
MG CAR CLUB OF TASMANIA INC ABN 42 028 552 599 GPO Box 5 Hobart Tasmania 7001 Preferred No Competitor Use Only Assigned No Club Use Only Class Club Use Only Paid Club Use Only ENTRY FORM (Legal Owner of the car) Baskerville Supersprints 22th April 2018 Entry Fee; $110.00 individual $150.00 Family (2) $30.00 additional Family member COMPETITOR DRIVER NAME (IN FULL) NAME (IN FULL) ADDRESS ADDRESS CAMS AFFILIATED CLUB CAMS AFFILIATED CLUB MEMBER NUMBER MEMBER NUMBER CAMS LICENCE NO. CAMS LICENCE NO. DATE OF BIRTH DATE OF BIRTH EMAIL ADDRESS Please indicate your permission, or otherwise, for notification of future events run by MGCCT by email: Yes, I wished to be notified No, I don’t wish to be notified DESCRIPTION OF VEHICLE MAKE MODEL BODY TYPE YEAR ENGINE CAPACITY TURBO or S/C Yes No FEE CASH CHEQUE MONEY ORDER AMOUNT $ CHARGE MY VISA MASTERCARD AMOUNT $ CARD No CARD EXPIRY AMOUNT $ CARD HOLDER’S NAME SIGNATURE OF CARD HOLDER SCRUTINY REPORT (CLUB USE ONLY) SPEED EVENTS 1 – 17 MOTORKHANA 9 – 17 ONLY Yes No Yes No 1 Safety helmet (AS 1698) □ □ 9 Brakes □ □ 2 Drivers apparel □ □ 10 Steering □ □ 3 Fire extinguisher (900gm min)) CERTIFICATION □ □ 11 Accelerator linkage □ □ 4 Seat belts – Condition Comply Aust. Standards (AS 2596, E35) □ □ 12 Fluid leaks oil, water, brake fluid □ □ 5 Bonnet (non extensible) □ □ 13 Suspension □ □ 6 Tail strap □ □ 14 Wheels and □ □ 7 Blue triangle □ □ 15 Fuel □ □ 8 Brake lights □ □ 16 Battery □ □ 17 Video camera □ □ Specify any other faults or relevant information PASSED NOT PASSED SIGNED: COMPETITOR DISCLAIMER PTO
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