2019 A4DE Vintage Nominations event registration

First Name *

Last Name *

Organization

Address *

Address 2

City *

State *

Post Code *

Country

Mobile Number *

Phone

Email *

Do your have an MA Competition Licence? *

You will be charged $90 for a one event licence. *

I Agree

Comment

MA Licence # *

MA Licence Expiry (DD/MM/YYYY) *

Road Licence # *

Road Licence Expiry

Next of Kin Name *

Next of Kin Contact number *

Medical Info (Allergies, Etc..)

Ambulance Fund

Fund Number

Vintage Class *

Bike Make *

Bike Model *

Bike Capacity *

Bike Type *

Do you have your own transponder *

You be charged $25 for hire of one for the event. *

I Agree

Transponder # *

Bike VIN Number *

Bike Engine Number *

Is your bike registered for road? *

Road Rego # *

Rego Expiry Date *

I understand that as my bike is not registered, it will require Temporary registration and as such will need to meet all conditions for a registered motorcycle (Lights, etc..) *

I understand

Year of Manufacture *

Do you want to ride with a mate. Put their name.

Amount

$

Payment processing fee

$

Gross amount

$

Payment Method

Paypal 2.8% Bank Fee

Billing Zipcode*

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Type*

Card Holder Name*

By registering for this event, I accept Terms and Conditions

Individual Registration

Payment Information

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