ENTRY APPLICATION
READ THIS FIRST
It is a requirement that this form is completed in full, in addition to any
previous forms, and signed. The Event Regulations must be read in conjunction
with this form before signing.
Please note that if your competition Licence is yet to be issued, please leave
the line empty so it can be filled in later.
DRIVER
(If car owner differs, note
name in brackets) CO-DRIVER
(full name, please print clearly)
Name:_____________________________________
Name:___________________________________
Address:___________________________________
Address:_________________________________
___________________________Postcode _______
________________________Postcode ________
Phone
home:______________wk: ______________ Phone
home:____________wk: ______________
Mobile:_________________Fax:
_______________ Mobile:_______________Fax:
_______________
E-mail: ____________________________________
E-mail: _________________________________
Male/Female (Circle one) Date
of Birth: __________ Male/Female (Circle one) Date of
Birth: ________
Occupation:
________________________________ Occupation:
______________________________
Driver’s Licence No:
_________________________ Driver’s Licence No:
_______________________
*Competition Licence No:
____________________ *Competition Licence No:
___________________
Issuing Club:
______________________________ Issuing Club:
_____________________________
The Co-driver will be
(circle one): Not driving Sharing drive
CAR DETAILS
Year:______ Make &
Model:_____________________________________ Registration No:__________
Colour:_____________________
Body style:_________________ Engine capacity:______________cc
4-wheel drive? YES / NO
(Circle) Is the car turbocharged
or supercharged? YES / NO (Circle)
Full registration /
Concessional license / permit / dealer plates - circle one
DISCLAIMER - EXCLUSION OF LIABILITY
RELEASE & ASSUMPTION OF RISK
I/We
being the entrant/s and/or driver, certify that the particulars on this form are
true and correct in every particular, to the best of my knowledge and belief.
I/We
declare that I/we have read and understood the Supplementary Regulations issued
for the event and agree to be bound by them and the provisions of the
Competition Rules of the Australian Auto-Sport Alliance Pty Ltd (AASA) - website:
www.aasa.com.au.
In
exchange for being able to attend or participate in the event (including
entering the event), I agree:
To release AASA, AEM, promoters, sponsor organisations, land owners and lessees,
organisers of the event, their respective servants, officials, representatives
and agents (collectively the “associated Entities”) from all liability for my
death, personal injury (including burns), psychological trauma, loss or damage
(including property damage) (”harm”) howsoever arising from my participation in
or attendance at the event, except to the extent prohibited by law;
That
AASA, AEM and Associated Entities do not make any warranty, implied or express,
that the event services will be provided with due care and skill or that any
materials provided in connection with the services will be fit for the purpose
for which they are supplied; and to attend or participate in the event at my own
risk.
I/we
acknowledge that: The risks associated with attending or participating in the
event include the risk that I may suffer harm as a result of: Motor vehicles (or
parts of them) colliding with other motor vehicles, persons or property; Acts of
violence or other harmful acts (whether intentional or inadvertent) committed by
persons attending or participating in the event; and the failure or
unsuitability of facilities (including grand-stands, fences and guard rails) to
ensure the safety of persons or property at the event.
Motor
sport is dangerous and accidents causing harm can and do happen and may happen
to me.
I
accept the conditions of, and acknowledge the risks arising from, attending or
participating in the event, and being provided with the event services by AASA,
AEM and the Associated Entities.
* COMPETITION LICENCES
AASA Club License
or approved equivalent standard competition licence is a minimum pre-requisite for both the Driver and
Co-driver. AEM can accept applications for AASA Licenses on request in advance.
Tick the box below if any person is requiring a AASA License to be issued ($50
each, for 12 months). AASA Licence Applications available on request. Forms
should be returned to AEM prior to the event. AEM does not issue CAMS Licenses.
DRIVER ____ Tick if AASA License required CO-DRIVER ____ Tick if AASA License required
FIRST AID KITS
Each car must
carry an approved First Aid Kit. These must be comprehensive kits. Your first
aid kit must be presented for checking when your car is checked at
Scrutineering. We recommend the St John Ambulance ‘Motor Major Trauma kit
#1231’. Contact St John Ambulance, St John Shop on 9334 1479 or go to their
website: www.ambulance.net.au
BEFORE YOU SIGN
Check and tick each of the following:
1. I have read and understood the Event Regulations ____
tick each line
2. I understand my
responsibility to pay for damage I cause ____
3. I have read the Entrants
Disclaimer/Indemnity above ____
SIGNATURES
Entrant
(ie: who is not the driver or co-driver):
_____________________________ date__________ Car owner:__________________________
date__________
Driver: _____________________________
date__________ Co-driver: ___________________________
date__________
PARENT OR LEGAL GUARDIAN PERMISSION - To be completed by the parent or legal guardian of any crew member who is under 18 years of age. I, being the Parent/Legal guardian of the crew member named below agree to his/her entry to the event.
Crew member:___________________________ Name of Parent/Guardian:____________________________
Signature:_________________________date___________
PAYMENT SUMMARY CHART
TAX INVOICE
AEM ABN 37256975662
Entry fee for the 2009
Shannons 1-Day Classic is $570 per car, plus the AASA fee of $70 per car. Full payment must
be sent with this form (in addition to any other amounts for licences), to
arrive at the AEM office no later than November 1st.
Post, email scanned version or deliver, please don’t fax. All costs are
inclusive of GST. A receipt can be sent on request.
Entry Fee
$ 570 (per car)
AASA Fee
+ $ 70 (compulsory
fee per car applied by AASA, the event insurers - not a competition license fee)
AASA Club License/s
($50 each - if required)
TOTAL $
PAYMENT
Payment may be made
by cheque or credit card. If paying by cheque, please make cheques out to AEM
and include with this form. Credit card payments below.
Circle card type: VISA
MASTERCARD
A 2%
credit card fee applies
Cardholder name _________________________________ Signature __________________________
Expiry date
____ /_____ Card number:
_ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _
Write clearly please!
Return this completed form no later than
November 1st, to:
AUTOMOTIVE EVENTS
MANAGEMENT - PO Box 1222, Subiaco, 6008
Or email scanned form (for credit card payments only)
info@classicrally.com.au
