Competition Entry Form

    [honeypot gender]

    DRIVER DETAILS

    DRIVERS NAME

    DRIVER MEMBERSHIP NUMBER (LAND ROVER CLUB IF NOT NWLRC)

    EMAIL

    ADDRESS

    PHONE

    EVENT DETAILS

    EVENT NAME

    EVENT DATE (DD-MM-YYYY)

    VEHICLE MODEL/CLASS

    OTHER ATTENDEE'S DETAILS

    PASSENGER NAME (AGE 14 OR OVER)

    PASSENGER MEMBERSHIP NUMBER (LAND ROVER CLUB IF NOT NWLRC)

    WILL VEHICLE BE DOUBLE DRIVEN

    YesNo

    NAME OF SECOND DRIVER (N/A IF NOT DOUBLE DRIVEN)

    Details of person to be notified in the event of a serious accident. This should NOT be your passenger.

    NAME

    ADDRESS

    PHONE

    RELATIONSHIP WITH COMPETITOR

    If the contact for passenger/co-driver is different to the above, please provide details here.

    DECLARATION – PLEASE READ BEFORE ACCEPTING

    The event will be held under the General Regulations of the Motor Sports Association (incorporating the provisions of the International Sporting Code of the FIA) and the Supplementary Regulations. I have read the general regulations of the Motor Sports Association and, if any, the Supplementary Regulations for this event and agree to be bound by them. I declare that I am physically and mentally fit to take part in the event and I am competent to do so. I acknowledge that I understand the nature and type of the competition and the potential risk inherent with motor sport and agree to accept that risk. Further I understand that all persons having any connection with the promotion and/or organisation and/or conduct of the event are insured against loss or injury caused through their negligence.

    BY TICKING THE BOX BELOW, YOU ARE CONFIRMING THAT ALL PARTICIPANTS (AND PARENT OR GUARDIAN FOR ANYONE UNDER 18) AGREE TO THE ABOVE TERMS.

    Click 'Send' below to submit details

    BANK TRANSFER PAYMENTS ONLY

    (PLEASE INCLUDE PAYMENT REFERENCE - eg Membership, RTV, CCV, Tyro)

    Bank details Account Name: NWLRC

    Sort Code: 40-39-16

    Account Number: 31150278

    Any queries please contact: nwlrc@btinternet.com

    SUBMIT AND PAY £21.00

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