DRIVER DETAILS:
First Name*
Surname*
Address:
House Name
House No and/or Road/Street
Village
Town*
County
Post Code*
Tel No. (Evening)*
Email
DOB of Driver*
MSA Licence No
Licence Grade & Category*
Select
Kart International
Kart National A
Kart National B
Non-Race National B
Off-Road International
Off-Road National A
Off-Road National B
Race International
Race National A
Race National B
Rally International
Rally National A Stage
Rally National A Navigator
Rally National B Stage
Speed International
Speed National A
Not Known
Do you hold, or have every held, a valid Road Traffic Act driving licence*
Select
Yes
No
?
CAR DETAILS:
Make & Model*
Exact Engine CC*
Super/Turbo Charged*
Select
Yes
No
?
Engine Type*
Select
Car
Motor Cycle
?
Will the car be running on Pump Fuel*
Select
Yes
No
?
If Not Pump Fuel, please state type
CLASS:
Saturday Class*
Select
Not Entering
A1
A2
A3
A4
B1
B2
B3
C1
C2
C3
C4
C5
C6
D1
D2
D3
D4
E1
E2
E3
M1
T1
Sunday Class*
Select
Not Entering
A1
A2
A3
A4
B1
B2
B3
C1
C2
C3
C4
C5
C6
D1
D2
D3
D4
E1
E2
E3
H1
CLUB DETAILS:
Saturday Motor Club (select only one)
Sunday Motor Club (select only one)
CHAMPIONSHIP SATURDAY:
MSCC Techniques Speed Championship*
Select
N/A
Yes
No
Revington TR/TR Register Sprint & Hillclimb Championship*
Select
N/A
Yes
No
Bridge Tyres & Wheels Wiscombe Hillclimb Championship*
Select
N/A
Yes
No
Hamilton Classic ACSMC Speed Hillclimb Championship*
Select
N/A
Yes
No
Trident Engineering WAMC Sprint & Hillclimb Championship*
Select
N/A
Yes
No
CHAMPIONSHIP SUNDAY:
Bridge Tyres & Wheels Wiscombe Hillclimb Championship*
Select
N/A
Yes
No
Hamilton Classic ACSMC Speed Hillclimb Championship*
Select
N/A
Yes
No
Trident Engineering WAMC Sprint & Hillclimb Championship*
Select
N/A
Yes
No
Bridge Tyres & Wheels ASWMC Hillclimb Championship*
Select
N/A
Yes
No
Healeysport Speed Series*
Select
N/A
Yes
No
The Toyo Tires Midland Speed*
Select
N/A
Yes
No
DOUBLE DRIVEN:
Car will also be driven by (additional Entry Form/Application needed)
Please state name of which driver is to be the "a" driver
FEES:
Entry Fee*
Select
Saturday £70.00
Sunday £70.00
Saturday & Sunday (both days) £140.00
I'm Paying via*
Select
Bank Transfer
PayPal
Cheque
Postal Order(s)
Cheque/Postal Order No(s)
If Paying by Cheque or Postal Orders, please make them Payable to "Five Clubs"
EMERGENCY CONTACT:
Name & Address of person to be contacted in case of an incident (do not state at the venue):
Name*
Tel No*
Address*
Relationship to Competitor*
Will this contact more than likely be at the event*
Select
Yes
No
DETAILS OF PERSON MAKING THIS APPLICATION:
First Name*
Surname*
Email Address of Person completing this Application*
IMPORTANT PLEASE READ BEFORE CLICKING SUBMIT
Your Entry will be marked as being received (on the date and time you submit this form on-line). If you are paying by PayPal or Bank Transfer we will email you with 24hrs with details on how to do this. If you are paying by cheque or postal orders you should send the correct payment asap. However you are paying for your entry you still need to send a printed version of this form (you can print this after clicking submit), then get the Driver to sign the entry form send it to us within 5 days of submitting this form online. If the printed copy of this form is received after 5 days (with the correct fee) it will be marked as being received on the date the printed version was received rather than the date of the on-line submitted copy.
Submitting this Entry Form, does not imply acceptance in to the event, acknowledgement of your entry will be sent to you in writing (via email), upon receipt of your Entry Fee and Printed/Signed copy of the Entry Form.
The condition of this on-line entry is that you have read and agree to all the supplementary regulations.
If entry is withdrawn any refund, if paying by PayPal, will not include the 3.4% PayPal fee paid, the refund will be based on the actual total entry fee, before the PayPal fee is added.
This site is not secure, the data is sent via email in the same way as any other email you send, if you do not wish to send the data via email, please complete an Entry Form by hand form the regs (a printed version of this form is not acceptable).
Data Protection Act: The above information will be stored in a computer retrieval system and will be used for organisational and publicity purposes.
It is the responsibility of the person submitting this entry to check if no acknowledgement is received after the posted entry form is submitted. If your entry is not received, no back dated applications will be accepted under any circumstances.
Do you agree with the above conditions*
No
Yes
