ENTRY APPLICATION FORM 

This form should be completed and returned to AEM with payment of a deposit of $300 (includes GST). Cheques should be made out to AEM. This application in no way implies acceptance of any applicant or vehicle. A refund will be made in the case of an application not being accepted. If you can, please include a photograph of your car suitable for use in publicity material. Full details and Supplementary Regulations will be sent to successful applicants. Places are strictly limited, so post (don’t fax), this form quickly.

CREW DETAILS    PLEASE PRINT CLEARLY
Driver name ________________________________________________________________

Address ___________________________________________________________________

______________________________________________________ Postcode ____________

Tel: work _______________________________ a/h _________________________________

Email  ____________________________________________________________________

Co-driver name  _____________________________________________________________

CAR DETAILS
Make _____________________________________________________________________

Model _____________________________________________________________________

Year _______ Engine capacity _________cc  Turbo or supercharged?  YES  or  NO  (circle)

Preferred competition number - up to 100 ________

PAYMENT OF DEPOSIT    A $300 deposit is required with this form. If paying by credit card (a $6 card fee applies), please complete below.

Circle which card:     VISA     MASTERCARD     BANKCARD 

Card number: 

________________    ________________    ______________    ______________ 

Cardholder name: ________________________________ Expiry date: ________ 

Signature: _____________________________________  Date: ______________

AUTOMOTIVE EVENTS MANAGEMENT

PO Box 1222, Subiaco, Western Australia, 6008